This section presents brief descriptions of each of the 12
PSIs covered in this report and explanations as to why it is important to report them publicly. Most of these adverse events are considered potentially preventable.

Foreign Body Left in During Procedure

• THIS INDICATOR IS MEASURED USING VOLUME OF OCCURRENCE - NOT A RATE - TELLS YOU the number of patients who had a foreign object accidentally left in their body during surgical or medical procedures. It is considered a never-event and happens very rarely. All cases with pre-existing conditions are excluded from the measure.
  
  
• THIS INFORMATION IS IMPORTANT because foreign objects such as sponges, medical instruments, bandages, should never be accidentally left in a patient’s body after an operation or procedure. This error is preventable, and hospitals with high rates need to put systems in place to prevent recurrences.

Iatrogenic Pneumothorax

• THIS RATE TELLS YOU the number of patients who had air leaking out of their lungs due to an accidental puncture during a medical or surgical procedure per 1,000 discharges. Iatrogenic means unfavorable response after a medical/surgical treatment and pneumothorax means a collapsed lung.
  
  
• THIS INFORMATION IS IMPORTANT because this medical error, which sometimes requires a tube in the patient’s chest to remove the extra air, is potentially avoidable.

Postoperative Hip Fracture

• THIS RATE TELLS YOU the number of patients who broke a hip bone from a fall during a hospital stay following any kind of operation or procedure per 1,000 surgery parients from the operating room.
  
  
• THIS INFORMATION IS IMPORTANT because when a patient falls after an operation and breaks his/her hip bone, it is a type of medical error that is usually preventable. A fall can happen for different reasons, such as receiving too much pain medication or having too little supervision when trying to walk after an operation. This is a very rare event.

Postoperative Hemorrhage or Hematoma

• THIS RATE TELLS YOU the number of patients with postoperative hemorrhage (too much bleeding) or postoperative hematoma (large blood clot) or drainage of hematoma per 1,000 surgical discharges following a surgical procedure
  
  
• THIS INFORMATION IS IMPORTANT because a hematoma is a large blood clot that can cause too much bleeding. Some of these complications may require another operation to stop the bleeding or remove the blood clots. This medical error is potentially avoidable.

Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)

• THIS RATE TELLS YOU the number of patients with PE, a blood clot in the lungs, or DVT, a blood clot in a large vein, per 1,000 discharges of surgery patients from the operating room. The number excludes obstetric patients.
  
  
• THIS INFORMATION IS IMPORTANT because a PE, which is a blood clot in the lungs, or DVT, which is a blood clot in a large vein, can occur during a surgical procedure. If the DVT breaks away and travels through the bloodstream, it could block a blood vessel in the patient’s lungs, causing PE.

Postoperative Sepsis

• THIS RATE TELLS YOU the number of hospitalized patients who get a serious bloodstream infection (nosocomial postoperative sepsis) after surgery per 1,000 elective surgery patients. A serious infection of the bloodstream caused by toxin-producing bacteria, known as sepsis, can occur after surgery.

  The rate excludes patients with preexisting infections (POA) as well as those with compromised immunity, such as cancer patients. Obstetric patients are also excluded.

• THIS INFORMATION IS IMPORTANT because it tells you the level of care provided by the hospital to prevent sepsis (infections) in patients. Analysis of these particular infections may provide a screen for potential medical errors and a method for monitoring trends in infections over time.

  Hospitals following the appropriate protocols, such as requiring staff frequently wash their hands, should see improvement of post-operative sepsis or other infections over time.

Postoperative Wound Dehiscence

• THIS RATE TELLS YOU the number of patients who had a re-closure of a surgical wound in the abdominal wall or pelvic area per 1,000 cases of abdominopelvic surgeries. Wound re-closure is performed after the wound from a surgical operation is accidently split open (wound dehiscence).

  Abdominopelvic surgical procedures include those performed on the stomach, liver, spleen, gallbladder, pancreas, kidneys, most of the small and large intestines, urinary bladder and internal reproductive organs. The rate excludes patients with pre-existing conditions (POA) and all obstetric admissions.

• THIS INFORMATION IS IMPORTANT because it shows you how often a surgical wound in the stomach or pelvic area is split open after an operation. Some or all of these complications may require treatment with another major operation to fix the wound. Wound dehiscence following surgery is a medical error that can be avoided.

Accidental Puncture or Laceration

• THIS RATE TELLS YOU the number of patients who had an accidental cut or laceration during a medical procedure per 1,000 discharges. The number excludes patients with pre-existing conditions (POA) as well as obstetric admissions.
  
  
• THIS INFORMATION IS IMPORTANT because such a cut or laceration can cause a hole or tear in an organ of the body while receiving medical treatment. This medical error can usually be avoided.

Transfusion Reaction

• THIS INDICATOR IS MEASURED USING VOLUME OF OCCURRENCE - NOT A RATE - TELLS YOU the number of patients who had a bad reaction to a blood transfusion. It is considered a never-event and happens very rarely. All cases with pre-existing conditions are excluded from the measure.
  
  
• THIS INFORMATION IS IMPORTANT because it measures major reactions to blood transfusions. Using the wrong type of blood or blood substitute are examples of why this type of medical error may occur.

Birth Trauma - Injury to Neonate

• THIS RATE TELLS YOU the number of birth trauma (injury to neonate) cases per 1,000 live births caused by medical complications during labor and delivery. The rate excludes some preterm infants and infants with osteogenic imperfecta.
  
  
• THIS INFORMATION IS IMPORTANT because some birth traumas are potentially preventable errors. Examples of what may cause a birth trauma to a neonate include: bleeding; delay ordering a medically necessary cesarean section (c-section); misuse of forceps or a vacuum extractor during delivery; or failure to respond to an umbilical cord that is dangerously wrapped around the newborn.

Obstetric Trauma - Vaginal Delivery with Instrument

• THIS RATE TELLS YOU the number of obstetric trauma cases to the mother (3rd or 4th degree lacerations, other obstetric lacerations) during instrument-assisted vaginal deliveries per 1,000 discharges.
  
  
• THIS INFORMATION IS IMPORTANT because trauma occuring during a vaginal delivery that requires the use of forceps or other instrument assistance is a medical error that is potentially preventable.

Obstetric Trauma - Vaginal Delivery without Instrument

• THIS RATE TELLS YOU the number of obstetric trauma cases to the mother (4th degree lacerations, other obstetric lacerations) per 1,000 vaginal deliveries that occurred without a medical instrument.
  
  
• THIS INFORMATION IS IMPORTANT because it tells you the number of potentially preventable injuries or lacerations that occurred during a vaginal delivery that did not require instrument assistance.

Please refer to the PSI Technical Report for a more detailed description and statistical analysis of the PSIs.

To view the data for Patient Safety Indicators, click on the following link:

 Patient Safety Indicators (PSI) Data

To learn more about the Patient Safety Indicator Data set and other data sets used on this web site, click on one of the following links:

 Understanding and Using Patient Safety Indicators

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