Table 1

Definitions of AHRQ patient safety indicators

Patient safety indicatorNumerator definitionDenominator definitionKey exclusions
All diagnosis based numerator definitions are based on secondary diagnoses unless otherwise noted.
DRG = diagnosis related group; MDC = major diagnostic category.
Anesthesia reactions and complicationsAdverse effects of or poisoning by anesthetic, endotracheal tube wrongly placedAll surgical dischargesPoisoning due to drug dependence or abuse, self-inflicted injury
Death in low mortality DRGsIn-hospital deathDRGs with less than 0.5% mortality in 1997 NISTrauma, cancer, immune compromise
Decubitus ulcerPressure ulcerAll medical and surgical discharges with >4 day stayMDC 9, admission from long term care, paralysis
Failure to rescueIn-hospital deathAcute renal failure, deep vein thrombosis, pulmonary embolus, pneumonia (including aspiration), shock, cardiac arrest, gastrointestinal hemorrhage/acute ulcerTransfer to or from acute care hospital, admission from long term care, principal diagnosis related to the denominator condition
Foreign body left during procedureForeign body accidentally left during procedureAll medical and surgical dischargesNone
Iatrogenic pneumothoraxIatrogenic pneumothoraxAll medical and surgical dischargesTrauma, cardiothoracic surgery, lung or pleural biopsy
Infection due to medical careInfection following infusion, injection, or transfusion, or due to vascular device or graftAll medical and surgical dischargesCancer, immune compromise
Postoperative hip fracturePostoperative hip fractureAll surgical dischargesMDC 8, self-inflicted injury, cancers possibly metastatic to bone, children, principal diagnosis that could cause syncope or falls
Postoperative hemorrhage/hematomaPostoperative hemorrhage/hematoma with surgical drainage or evacuationAll surgical dischargesObstetric discharges
Postoperative physiological or metabolic derangementPostoperative acute renal failure requiring dialysis or diabetic ketoacidosis, hyperosmolarity, or hypoglycaemic comaAll elective surgical dischargesObstetric discharges, principal diagnosis causally related to the numerator condition
Postoperative respiratory failurePostoperative acute or acute on chronic respiratory failureAll elective surgical dischargesMDC 4, MDC 5, obstetric discharges
Postoperative thromboembolismPostoperative deep vein thrombosis or pulmonary embolusAll surgical dischargesObstetric discharges, principal diagnosis of deep vein thrombosis
Postoperative septicemiaPostoperative septicemiaAll elective surgical discharges with >3 day stayCancer, infection, immune compromise, obstetric discharges
Postoperative abdominopelvic wound dehiscenceSecondary procedure to close postoperative disruption of abdominal wallAll abdominopelvic surgical dischargesObstetric discharges
Accidental puncture or lacerationAccidental puncture or laceration during procedureAll medical and surgical dischargesObstetric discharges
Transfusion reactionABO or Rh transfusion reactionAll medical and surgical dischargesNone
Birth traumaIntracranial hemorrhage, extraclavicular fracture, spinal injury, nerve injury (other than facial and brachial plexus), other birth traumaAll live birthsPreterm infants (for intracranial hemorrhage), osteogenesis imperfecta (for fracture)
Obstetric trauma (vaginal with instrumentation)Principal or secondary diagnosis of fourth degree perineal, high vaginal, or cervical laceration; or procedure to repair any of these lacerationsAll vaginal deliveries with forceps or vacuumNone
Obstetric trauma (vaginal without instrumentation)SameAll vaginal deliveries without forceps or vacuumNone
Obstetric trauma (caesarean)Same + uterine or urinary tract laceration; or procedure to repair any of these lacerationsAll cesarean deliveriesNone