Reduce Harm Breakout Group
What is Harm?
The National Quality Forum’s definition of harm is: Any physical or psychological injury or damage to
the health of a person, including both temporary and permanent injury.
How is Harm Identified?
Voluntary reporting
Patient safety reports. UF&Shands uses IDinc to report and track patient safety events.
A high percent of harms are not reported which are believed to be a result of the
reporting systems, time constraints, fear of reprisal, shame, lack of feedback, etc.
Administrative data sets
Captured through ICD-9 codes and demographic data in the medical record. Benefit
from objective criteria but limited by quality of documentation and coding as well as lack of
contextual clinical information. Able to determine rates.
Trigger tools
Captured through medical record audit. Triggers are clues for possible harm. Further
investigation into harm (and degree) is required. Able to trend rates.
Recognized Harm Measures:
NQF Serious Reportable Events
Surgical Events
Surgery performed on the wrong body part
Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient
Unintended retention of a foreign object in a patient after surgery or other procedure
Intraoperative or immediately postoperative death in a ASA Class I patient
Product or Device Events
Patient death or serious disability associated with the use of contaminated drugs, devices or
biologics provided by the healthcare facility
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 cared for in a healthcare facility
Patient Protection Events
Infant discharged to the wrong person
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a
healthcare facility
Care Management Events
Patient death or serious disability associated with a medication error (e.g. errors involving the
wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of
administration)
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
hyperbilirubinermia 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
Artificial insemination with the wrong donor sperm or wrong egg
Environmental Events
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
Criminal Events
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 a healthcare facility
Death or significant injury of a patient or staff member resulting form a physical assault (i.e.
battery) that occurs within or on the grounds of a healthcare facility
AHRQ Patient Safety Indicators
EXP 01 Rate of Complications of Anesthesia
EXP 02 Obstetric Trauma Rate - Cesarean Delivery
PSI 02 Death in Low-Mortality Diagnosis Related Groups (DRGs)
PSI 03 Pressure Ulcer Rate
PSI 04 Death among Surgical Inpatients
PSI 05 Foreign Body Left During Procedure
PSI 06 Iatrogenic Pneumothorax Rate
PSI 07 Central Venous Catheter-Related Blood Stream Infection
PSI 08 Postoperative Hip Fracture Rate
PSI 09 Postoperative Hemorrhage or Hematoma Rate
PSI 10 Postoperative Physiologic and Metabolic Derangement Rate
PSI 11 Postoperative Respiratory Failure Rate
PSI 12 Postoperative PE or DVT Rate
PSI 13 Postoperative Sepsis Rate
PSI 14 Postoperative Wound Dehiscence Rate
PSI 15 Accidental Puncture or Laceration Rate
PSI 16 Transfusion Reaction Volume
PSI 17 Birth Trauma Rate―Injury to Neonate
PSI 18 Obstetric Trauma Rate―Vaginal Delivery With Instrument
PSI 19 Obstetric Trauma Rate-Vaginal Delivery wo Instrument
PSI 21 Rate of Foreign Body Left During Procedure
AHRQ Pediatric Quality Indicators
NQI 01 Neonatal Iatrogenic Pneumothorax Rate
NQI 02 Neonatal Mortality Rate
NQI 03 Neonatal Blood Stream Infection Rate
PDI 01 Accidental Puncture or Laceration Rate
PDI 02 Pressure Ulcer Rate
PDI 03 Foreign Body Left During Procedure
PDI 05 Iatrogenic Pneumothorax Rate
PDI 06 Pediatric Heart Surgery Mortality Rate
PDI 07 Pediatric Heart Surgery Volume
PDI 08 Postoperative Hemorrhage or Hematoma Rate
PDI 09 Postoperative Respiratory Failure Rate
PDI 10 Postoperative Sepsis Rate
PDI 11 Postoperative Wound Dehiscence Rate
PDI 12 Central Venous Catheter-Related Blood Stream Infection Rate
PDI 13 Transfusion Reaction Volume
PDI 14 Asthma Admission Rate
PDI 15 Diabetes Short-term Complications Admission Rate
PDI 16 Gastroenteritis Admission Rate
PDI 17 Perforated Appendix Admission Rate
PDI 18 Urinary Tract Infection Admission Rate
AHRQ Prevention Quality Indicators
PQI 01 Diabetes Short-term Complications Admissions Rate
PQI 02 Perforated Appendix Admission Rate
PQI 03 Diabetes Long-term Complications Admission Rate
PQI 05 COPD or Asthma in Older Adults Admission Rate
PQI 07 Hypertension Admission Rate
PQI 08 Heart Failure Admission Rate
PQI 09 Low Birth Weight Rate
PQI 10 Dehydration Admission Rate
PQI 11 Bacterial Pneumonia Admission Rate
PQI 12 Urinary Tract Infection Admission Rate
PQI 13 Angina without Procedure Admission Rate
PQI 14 Uncontrolled Diabetes Admission Rate
PQI 15 Asthma in Younger Adults Admission Rate
PQI 16 Rate of Lower-Extremity Amputation Diabetes
Hospital Acquired Conditions
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers
Falls and Trauma
Fractures
Dislocations
Intracranial Injuries
Crushing Injuries
Burn
Other Injuries
Manifestations of Poor Glycemic Control
Diabetic Ketoacidosis
Nonketotic Hyperosmolar Coma
Hypoglycemic Coma
Secondary Diabetes with Ketoacidosis
Secondary Diabetes with Hyperosmolarity
Catheter-Associated Urinary Tract Infection (UTI)
Vascular Catheter-Associated Infection
Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
Surgical Site Infection Following Bariatric Surgery for Obesity
Laparoscopic Gastric Bypass
Gastroenterostomy
Laparoscopic Gastric Restrictive Surgery
Surgical Site Infection Following Certain Orthopedic Procedures
Spine
Neck
Shoulder
Elbow
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic
Procedures:
Total Knee Replacement
Hip Replacement
Mortality Rates
Infection Rates
Central Line Associated Blood Stream Infection
Catheter Associated Urinary Tract Infection
Ventilator Associated Pneumonia
Surgical Site Infections
Clostridium Difficile
Vancomycin Resistent Enterococcus
Discipline Specific Complications
Known risks for interventions
Medication Related Harm
Available Harm Reports
UHC Quality and Safety Report
AHCA/CMS – publicly reported and delayed
Patient Safety Reports
How are We Working to Reduce Harm?
Root Cause Analysis of serious events
Review and respond to patient safety reports
Morbidity & Mortality Conferences
Review of AHRQ PSIs/PQIs, and HACs
Mortality Review
Performance Improvement Teams
Current Harm Metrics