The federal Agency for Healthcare Research and Quality (AHRQ) developed this quality measure to help hospitals easily detect preventable harms to patients using billing records.
Deeper dive
In the early 2000s, AHRQ launched patient safety indicators (PSIs) to help health care systems detect adverse events and identify potential areas of improvement. PSIs focus on preventable complications and harms caused by medical interventions, which are known as iatrogenic events. The agency periodically updates its list of PSIs, most recently in 2023. Examples include deaths of patients who were diagnosed with a condition associated with a low mortality; pressure ulcers; deaths among surgical patients who were diagnosed with a serious but treatable condition such as deep vein thrombosis or pneumonia; in-hospital falls with hip fractures; and trauma injuries to newborns. Hospital and clinic administrators can use free software to analyze their administrative (also known as billing or discharge) data and find potential areas for quality improvement. PSIs were developed as an internal quality improvement tool for hospitals but have expanded to state-based public reporting and pay-for-performance initiatives. However, PSIs are limited in their usefulness because they are based on administrative data rather than detailed electronic health records. One study of several PSIs concluded that they can identify potential safety incidents from a huge database of admissions, which can then be verified through chart reviews. However, PSIs may miss cases due to under-coding. A study of accidental lacerations found that a PSI accurately identified accidental injuries due to medical care but injuries were often inconsequential or reflected acceptable risks.