Indicator Goal Met Indicator Goal Not Met BM = Benchmark
| Indicator | Goal | BM | Jul | Aug | Sep | Oct | Nov | Dec | Jan | Feb | Mar | Apr | May | Jun | Avg |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| WORKSITE SAFETY TEAM | |||||||||||||||
| Incident Rate of Total Recordable Injuries | ≤5.13 | 2.5 | 2.68 | 1.28 | 4.66 | 2.54 | 2.68 | 3.32 | 3.28 | 4.11 | 3.86 | 2.06 | 3.38 | 3.08 | |
| Exposure Rate – Sharps Injuries | YTD ≤ 18.8 Monthly ≤1.56 |
YTD ≤ 18.8 Monthly ≤1.56 |
0.74 | 0.66 | 0.65 | 1.47 | 0.72 | 1.45 | 1.96 | 0.60 | 2.50 | 2.07 | 3.57 | 17.01 | |
| EOS - Work Environment Satisfaction | ≥90th | 90th | 99 | 99 | |||||||||||
| PATIENT SAFETY TEAM | |||||||||||||||
| Number of Sentinel Events | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 3 | ||
| Inpatient Falls | ≤0.20% | ≤0.24% | 0.08 | 0.14 | 0.24 | 0.20 | 0.14 | 0.17 | 0.15 | 0.29 | 0.14 | 0.18 | 0.14 | 0.17 | |
| Inpatient Satisfaction “ID Bracelet Checked Before Giving Medications” | ≥90th | 90th | 95 | 93 | 91 | 99 | 96 | 93 | |||||||
| Patient Safety Index | ≤0.84 | 0.84 | 0.67 | 0.53 | 0.50 | 0.83 | 0.84 | 0.81 | .89 | 0.91 | .89 | .89 | 0.89 | ||
| Decubitus Ulcer | ≤23.1 | 23.1 | 0 | 11.80 | 19.3 | 21.63 | 20.42 | 21.43 | 16.70 | 13.80 | 12.4 | 13.2 | 13.2 | ||
| Failure to Rescue | ≤129.1 | 129.1 | 176 | 108 | 90.9 | 54.34 | 30.61 | 42.6 | 50 | 64.5 | 63.4 | 60.9 | 60.9 | ||
| Postoperative Sepsis | ≤11.85 | 11.85 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Selected Infections Due to Medical Care | ≤2.06 | 2.06 | 0 | 1.63 | 1.1 | 0.9 | 0.61 | 0.50 | 2.0 | 2.0 | 1.8 | 1.4 | 1.4 | ||
| Post-op Hemorrhage or Hematoma | ≤1.98 | 1.98 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Post-op Physiologic and Metabolic Derangement | ≤1.26 | 1.26 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Post-op Respiratory Failure | ≤4.46 | 4.46 | 166 | 90.9 | 58.8 | 50.0 | 42.1 | 38.6 | 36.4 | 28.4 | 26.4 | 24.1 | 24.1 | ||
| Post-op Pulmonary Embolus or Deep Vein Thrombosis | ≤7.38 | 7.38 | 57 | 20.13 | 21.93 | 23.25 | 22.9 | 24.8 | 18.98 | 17.75 | 16.5 | 15.8 | 15.8 | ||
| Iatrogenic Pneumothorax | ≤.783 | .783 | 0 | 0 | 0 | 0.63 | 0.61 | 0.52 | 0.8 | 1.18 | 1.0 | .91 | .91 | ||
| Post-op wound Dehiscence in abdominopelvic Surgical Patients | ≤1.83 | 1.83 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 10.75 | 9.8 | 9.7 | 9.7 | ||
| V.T.E. Prophylaxis Ordered for Surgery Patients | ≥94 | 97 | 50 | 87 | 98 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 96 | |
| V.T.E. Prophylaxis Received Within 24 Hours Prior to or After Surgery | ≥93 | 95 | 46 | 87 | 94 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 95 |
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.
Sharps Injuries include needlesticks, lacerations, punctures, etc. with an exposure of blood or body fluid from another person.
Employees who are satisfied with their work environment as indicated in the Employee Opinion Survey, reported annually.
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.
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.
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 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 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/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/1000 discharges (excluding immunocompromised and cancer patients and neonates) (PSI 7)
Postoperative hemorrhage or hematoma with surgical drainage or evacuation, not verifiable as following surgery, per 1000 surgical discharges (excluding obstetrical admissions) (PSI 9)
Postoperative physiologic and metabolic derangements/1000 elective surgical discharges (excluding some serious disease and obstetric admissions) (PSI 10)
Postoperative Respiratory failure/1000 elective surgical discharges (excluding patients with respiratory disease, circulatory disease, and obstetric conditions) (PSI 11)
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/1000 discharges (excluding neonates, obstetrical admissions, and patients with trauma, thoracic surgery, lung or pleural biopsy, or cardiac surgery) (PSI 6)
Reclosure of postoperative disruption of abdominal wall (postoperative abdominal wound dehiscence)/1000 abdominopelvic – surgery discharges (excluding obstetrical conditions) (PSI 14)
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.