Safety Report :: Strategic Value Reports

SOMC Safety Dashboard: Fiscal Year 2009

Indicator Goal Met Indicator Goal Not Met BM = Benchmark

Indicator	Goal	BM	Jul	Aug	Sep	Oct	0Nov	Dec	Jan	Feb	Mar	Apr	May	Jun	Avg
IMPROVE WORKSITE SAFETY	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Incident Rate of Total Recordable Injuries	≤5.13	2.5	2.10	2.0	2.80	2.6	4.09	4.84	3.4	0.70	2.6	2.7	2.6	2.70	2.76
Exposure Rate – Sharps Injuries	YTD ≤ 18.8 Monthly ≤1.56	YTD ≤ 18.8 Monthly ≤1.56	1.52	0.79	0.70	1.41	3.70	2.05	2.67	0.66	1.28	1.43	0.65	3.62	19.35
IMPROVE PATIENT SAFETY	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Blood Incompatibility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Air Embolism	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Deep Vein Thrombosis and Pulmonary Embolism Following Total and Partial Hip Replacement and Total Knee Replacement	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Stage III and IV Pressure Ulcer	0	0	0	0	0	0	0	0	1	0	0	0	0	0	1
Iatrogenic Pneumothorax, Adult	≤0.83	0	2.4	0	0	0	0.76	0.63	.74	0.83	.80	0.72	0.77	1.37	1.37
PATIENT SAFETY SURGICAL INDICATORS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Postoperative Wound Dehiscence	≤8.64	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Accidental Puncture or Laceration	≤4.54/1000 Discharges	<4.54	0	3.94	4.3	2.59	1.38	1.15	1.17	1.02	0.92	0.95	0.97	0.94	0.94
Manifestations of Poor Glycemic Control	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Retention of Foreign Object After Surgery or Death	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
PATIENT SAFETY INFECTION INDICATORS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Surgical Site Infection Following Certain Orthopedic Procedures	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Mediastinitis After CABG	0	0	N/A	N/A	N/A	N/A	N/A	0	0	0	0	0	0	0	0
Catheter-Associated Vascular Infection	0	0	1	0		0	0	0	0	0	0	0	0	0	1
Catheter-Associated UTI	≤38/year ≤3.2/month	0	3	3	3	1	2	0	3	4	2	2	1	0	23
PATIENT SAFETY FALL & TRAUMAS INDICATORS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Fractures	0	0	0	0	0	1	0	0	0	0	0	0	0	1	2
Dislocations	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Electric Shock	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Intracranial Injuries	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Crushing Injuries	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Burns	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
PATIENT SAFETY NURSING SENSITIVE INDICATORS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Failure to Rescue	≤57.1	<57.1	0	0	100	84	67	56	52	56.8	50	45	41	39	39
PATIENT SAFETY MORTALITY RATE INDICATORS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Abdominal Aortic Aneurysm (with or Without Volume)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Hip Fracture	0	0	1	0	0	0	0	0	0	0	0	0	0	0	1
CMS Non-Risk Adjusted Medicare Mortality Rate	≤2.75		2.17	1.91	2.09	1.02	1.05	2.83	2.51	2.80	2.37	2.14	1.24	1.89	2.01
CMS Non–Risk Adjusted AMI 30 Day Mortality	≤14.4		0	0	0	16.67	28.75	22.22	18.18	0	15.38	10.0	0		11.83
CMS Non-Risk Adjusted HF 30 Day Mortality	≤8.75		7.41	16.0	12.5	3.85	9.68	17.86	21.43	21.21	5.13	0	2.44	17.95	11.14
CMS Non-Risk Adjusted PN 30 Day Mortality	≤8.3		6.25	5.0	10.53	0	8.33	25.0	9.09	10.0	12.0	5.26	12.5	14.3	9.82
CMS FY08 AMI 30 Day Risk Standardized Mortality Rate	≤RSMR (Annual)											20.8			20.8
CMS FY08 HF 30 Day Risk Standardized Mortality Rate	≤RSMR (Annual)											9.2			9.2
CMS FY08 PN 30 Day Risk Standardized Mortality Rate	≤RSMR (Annual)											9.7			9.7
HF 30 Day Risk Standardized Readmission Measure	≤RSMR (Annual)	Expected										25			25
NATIONAL QUALITY FORUM (NQF) NEVER EVENTS	GOAL	BM	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	AVG
Surgery Performed on the Wrong Body Part	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Surgery Performed on the Wrong Patient	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Unintended Retention of a Foreign Object in a Patient After Surgery or Other Procedure	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Intraoperative or Immediately Post-Operative Death in an ASA Class I Patient	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with the use or Function of a Device in Patient Care, in Which the Device is used or functions Other Than as Intended	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with Intravascular Air Embolism that Occurs While Being Care for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Infant Discharge to the Wrong Person	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with Patient Elopement	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Suicide or Attempted Suicide Resulting in Serious Disability, While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with a Medication Error	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with a Hemolytic Reaction due to the Administration of ABO/HLA – Incompatible Blood or Blood Products	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Maternal Death or Serious Disability Associated with Labor or Delivery in a Low-risk Pregnancy While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with Hypoglycemia, the Onset of Which Occurs While the Patient is Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Death or Serious Disability (kernicterus) Associated with Failure to Identify and Treat Hypervilirubinemia in Neonates	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Stage 3 or 4 Pressure Ulcers Acquired After Admission to a Healthcare Facility	0	0	0	0	0	0	0	0	1	0	0	0	0	0	1
Patient Death or Serious Disability due to Spinal Manipulative Therapy	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability due to Spinal Manipulative Therapy	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with an Electric Shock While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Any Incident in Which a Line Designated for Oxygen or Other gas to be Delivered to a Patient Contains the Wrong Gas or is Contaminated by Toxic Substances	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with a Burn Incurred from any Source While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with a Fall While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Serious Disability Associated with the use of Restraints or Bedrails While Being Cared for in a Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Any Instance of Care Ordered by or Provided by Someone Impersonating a Physician, Nurse, Pharmacist or other Licensed Healthcare Provider	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Abduction of a Patient of any age	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Sexual Assault on a Patient Within or on the Grounds of the Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Patient Death or Significant Injury of a Patient or Staff Member Resulting From a Physical Assault that Occurs within or the Grounds of the Healthcare Facility	0	0	0	0	0	0	0	0	1	0	0	0	0	0	1
Patient Death or Serious Disability Associated with the use of Contaminated Drugs, Devices, or Biologics Provided by the Healthcare Facility	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0

Indicator

Goal

Jul

Aug

Sep

Oct

0Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Avg

IMPROVE WORKSITE SAFETY

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Incident Rate of Total Recordable Injuries

≤5.13

2.5

2.10

2.0

2.80

2.6

4.09

4.84

3.4

0.70

2.6

2.7

2.6

2.70

2.76

Exposure Rate – Sharps Injuries

YTD ≤ 18.8
Monthly ≤1.56

1.52

0.79

0.70

1.41

3.70

2.05

2.67

0.66

1.28

1.43

0.65

3.62

19.35

IMPROVE PATIENT SAFETY

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Blood Incompatibility

Air Embolism

Deep Vein Thrombosis and Pulmonary Embolism Following Total and
Partial Hip Replacement and Total Knee Replacement

Stage III and IV Pressure Ulcer

Iatrogenic Pneumothorax, Adult

≤0.83

2.4

0.76

0.63

.74

0.83

.80

0.72

0.77

1.37

PATIENT SAFETY SURGICAL INDICATORS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Postoperative Wound Dehiscence

≤8.64

Accidental Puncture or Laceration

≤4.54/1000 Discharges

<4.54

3.94

4.3

2.59

1.38

1.15

1.17

1.02

0.92

0.95

0.97

0.94

Manifestations of Poor Glycemic Control

Patient Retention of Foreign Object After Surgery or Death

PATIENT SAFETY INFECTION INDICATORS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Surgical Site Infection Following Certain Orthopedic Procedures

Mediastinitis After CABG

N/A

Catheter-Associated Vascular Infection

Catheter-Associated UTI

≤38/year
≤3.2/month

PATIENT SAFETY FALL & TRAUMAS INDICATORS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Fractures

Dislocations

Electric Shock

Intracranial Injuries

Crushing Injuries

Burns

PATIENT SAFETY NURSING SENSITIVE INDICATORS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Failure to Rescue

≤57.1

<57.1

100

56.8

PATIENT SAFETY MORTALITY RATE INDICATORS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Abdominal Aortic Aneurysm (with or Without Volume)

Hip Fracture

CMS Non-Risk Adjusted Medicare Mortality Rate

≤2.75

2.17

1.91

2.09

1.02

1.05

2.83

2.51

2.80

2.37

2.14

1.24

1.89

2.01

CMS Non–Risk Adjusted AMI 30 Day Mortality

≤14.4

16.67

28.75

22.22

18.18

15.38

10.0

11.83

CMS Non-Risk Adjusted HF 30 Day Mortality

≤8.75

7.41

16.0

12.5

3.85

9.68

17.86

21.43

21.21

5.13

2.44

17.95

11.14

CMS Non-Risk Adjusted PN 30 Day Mortality

≤8.3

6.25

5.0

10.53

8.33

25.0

9.09

10.0

12.0

5.26

12.5

14.3

9.82

CMS FY08 AMI 30 Day Risk Standardized Mortality Rate

≤RSMR (Annual)

20.8

CMS FY08 HF 30 Day Risk Standardized Mortality Rate

≤RSMR (Annual)

9.2

CMS FY08 PN 30 Day Risk Standardized Mortality Rate

≤RSMR (Annual)

9.7

HF 30 Day Risk Standardized Readmission Measure

≤RSMR (Annual)

Expected

NATIONAL QUALITY FORUM (NQF) NEVER EVENTS

GOAL

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

AVG

Surgery Performed on the Wrong Body Part

Surgery Performed on the Wrong Patient

Unintended Retention of a Foreign Object in a Patient After Surgery or Other Procedure

Intraoperative or Immediately Post-Operative Death in an ASA Class I Patient

Patient Death or Serious Disability Associated with the use or Function of a Device
in Patient Care, in Which the Device is used or functions Other Than as Intended

Patient Death or Serious Disability Associated with Intravascular Air Embolism
that Occurs While Being Care for in a Healthcare Facility

Infant Discharge to the Wrong Person

Patient Death or Serious Disability Associated with Patient Elopement

Patient Suicide or Attempted Suicide Resulting in
Serious Disability, While Being Cared for in a Healthcare Facility

Patient Death or Serious Disability Associated with a Medication Error

Patient Death or Serious Disability Associated with a Hemolytic Reaction
due to the Administration of ABO/HLA – Incompatible Blood or Blood Products

Maternal Death or Serious Disability Associated with Labor or Delivery
in a Low-risk Pregnancy While Being Cared for in a Healthcare Facility

Patient Death or Serious Disability Associated with Hypoglycemia,
the Onset of Which Occurs While the Patient is Being Cared for in a Healthcare Facility

Death or Serious Disability (kernicterus) Associated with
Failure to Identify and Treat Hypervilirubinemia in Neonates

Stage 3 or 4 Pressure Ulcers Acquired After Admission to a Healthcare Facility

Patient Death or Serious Disability due to Spinal Manipulative Therapy

Patient Death or Serious Disability Associated with an
Electric Shock While Being Cared for in a Healthcare Facility

Any Incident in Which a Line Designated for Oxygen or Other gas to be Delivered
to a Patient Contains the Wrong Gas or is Contaminated by Toxic Substances

Patient Death or Serious Disability Associated with a Burn Incurred from
any Source While Being Cared for in a Healthcare Facility

Patient Death or Serious Disability Associated with a
Fall While Being Cared for in a Healthcare Facility

Patient Death or Serious Disability Associated with the use of
Restraints or Bedrails While Being Cared for in a Healthcare Facility

Any Instance of Care Ordered by or Provided by Someone Impersonating
a Physician, Nurse, Pharmacist or other Licensed Healthcare Provider

Abduction of a Patient of any age

Sexual Assault on a Patient Within or on the Grounds of the Healthcare Facility

Patient Death or Significant Injury of a Patient or Staff Member Resulting From a
Physical Assault that Occurs within or the Grounds of the Healthcare Facility

Patient Death or Serious Disability Associated with the use of Contaminated Drugs,
Devices, or Biologics Provided by the Healthcare Facility

Incident Rate of Total Recordable Injuries

Departmental data is total number of employee recordable injuries. The comparative data is OSHA’s national rate. OSHA does not provide rates that are specific to a hospital department so our data has no department-specific comparison.

Exposure Rate – Sharps Injuries

Sharps Injuries include needlesticks, lacerations, punctures, etc. with an exposure of blood or body fluid from another person.

Employee Opinion Survey (EOS) - Work Environment Satisfaction

Employees who are satisfied with their work environment as indicated in the Employee Opinion Survey, reported annually.

Number of Sentinel Events

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.

Inpatient Falls

A patient fall is an unplanned descent to the floor (or extension of the floor, e.g., trash can or other equipment) with or without injury to the patient, and occurs on an eligible reporting nursing unit.

Patient Safety Index (PSI)

For each of the ten PSIs, we calculated an index value based on the number of actual PSI occurrences for 2004 and 2005, combined, divided by the number of normalized expected occurrences, given the risk of the PSI event for each patient. Values were normalized by comparison group. The Hospital-Level PSI methodology from AHRQ was applied to the 2004 and 2005 MedPAR acute care data, using program code provided by AHRQ to adjust for risk.

The reference value for this index is 1.00; a value of 1.15 indicates 15 percent more events than predicted, and a value of 0.85 indicates 15 percent fewer.

Decubitus Ulcer

Decubitus ulcers/1000 discharges of length 5 or more days (excluding paralysis patients, patients admitted from long-term care facilities, patients with diseases of the skin, subcutaneous tissue, and breast, and obstetrical admissions) (PSI 3)

Failure to Rescue

Failure to rescue or deaths/1000 discharges having developed specified complications of care during hospitalization (excluding patients transferred in or out, patients admitted from long-term care facilities, neonates, and patients over 74 years old) (PSI 4)

Postoperative Sepsis

Postoperative Sepsis/1000 elective-surgery discharges of longer than 3 days (excluding patients admitted for infection; patients with cancer or immunocompromised states, and obstetric conditions) (PSI 13)

Selected Infections Due to Medical Care

Selected infections due to medical care/1000 discharges (excluding immunocompromised and cancer patients and neonates) (PSI 7)

Post-op Hemorrhage or Hematoma

Postoperative hemorrhage or hematoma with surgical drainage or evacuation, not verifiable as following surgery, per 1000 surgical discharges (excluding obstetrical admissions) (PSI 9)

Post-op Physiologic and Metabolic Derangement

Postoperative physiologic and metabolic derangements/1000 elective surgical discharges (excluding some serious disease and obstetric admissions) (PSI 10)

Post-op Respiratory Failure

Postoperative Respiratory failure/1000 elective surgical discharges (excluding patients with respiratory disease, circulatory disease, and obstetric conditions) (PSI 11)

Post-op Pulmonary Embolus or Deep Vein Thrombosis

Postoperative pulmonary embolus (PE) or deep vein thrombosis (DVT)/1000 surgical discharges (excluding patients admitted for DVT, obstetrics, and plication of vena cava before or after surgery) (PSI 12)

Iatrogenic Pneumothorax

Iatrogenic pneumothorax/1000 discharges (excluding neonates, obstetrical admissions, and patients with trauma, thoracic surgery, lung or pleural biopsy, or cardiac surgery) (PSI 6)

Post-op wound Dehiscence in abdominopelvic Surgical Patients

Reclosure of postoperative disruption of abdominal wall (postoperative abdominal wound dehiscence)/1000 abdominopelvic – surgery discharges (excluding obstetrical conditions) (PSI 14)

Benchmark Information

SOMC uses The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators as the benchmark for Safety. These indicators help us identify potential adverse events occuring during hospitalization.

AHRQ is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decisionmaking.