Definitions of AHRQ Patient Safety Indicators

Patient Safety IndicatorNumerator (Subset of Denominator Pool)DenominatorKey Exclusions
Complications of anesthesiaAnesthetic overdose, reaction, endotrachial tube misplacementAll surgical dischargesPoisoning as a result of drug dependence or abuse, self-inflicted injury
Death in low-mortality DRGDischarges with disposition of “deceased”All discharges in DRGs with <0.5% mortality rate based on National Inpatient Sample data for 1997Trauma, immunocompromised state, cancer
Decubitus ulcerPressure ulcerAll medical and surgical discharges with >4-d stayHemiplegia, paraplegia or quadriplegia, paralysis, obstetric discharge, admission from long-term care facilities
Failure to rescueDischarges with a disposition of “deceased”All discharges with potential complication of care (eg, pneumonia, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal hemorrhage)Exclusions specific to each diagnosis (eg, pneumonia excludes immunocompromised state, viral pneumonias; sepsis excludes immunocompromised state, records with primary diagnosis of infection, and records with LOS >3 d)
Foreign body left during procedureForeign body accidentally left during procedureAll medical and surgical dischargesNone
Iatrogenic pneumothoraxIatrogenic pneumothoraxAll medical and surgical dischargesTrauma, cardiothoracic surgery, lung or pleural biopsy, obstetric discharge
Selected infection as a result of medical careInfection after infusion, injection, or transfusion, or as a result of vascular device or graftAll medical and surgical dischargesCancer, immune compromise
Postoperative hip fracturePostoperative in-hospital hip fractureAll surgical dischargesMusculoskeletal diseases, seizure, syncope, stroke, coma, cardiac arrest, anoxic brain injury, poisoning, delirium, trauma, self-inflicted injury, cancers metastatic to bone
Postoperative hemorrhage/hematomaPostoperative hemorrhage/hematoma with surgical drainage or evacuationAll surgical dischargesObstetric discharge
Postoperative physiologic or metabolic derangementsPostoperative physiologic or metabolic derangement; acute renal failure cases must be accompanied by code for dialysisAll elective surgical dischargesKetoacidosis, hyperosmolarity, or coma with a principal diagnosis of diabetes; secondary diagnosis of acute renal failure with a principal diagnosis of acute myocardial infarction, cardiac arrhythmia, cardiac arrest, shock, hemorrhage, or gastrointestinal hemorrhage; obstetric discharges
Postoperative respiratory failurePostoperative acute respiratory failureAll elective surgical dischargesRespiratory or circulatory diseases, obstetric discharge
Postoperative pulmonary embolism or deep vein thrombosisPostoperative deep vein thrombosis or pulmonary embolismAll surgical dischargesObstetric discharge, principal diagnosis of deep vein thrombosis, obstetric patients
Postoperative sepsisPostoperative sepsisAll elective surgical discharges with >3-d stayCancer, infection, immune compromise, obstetric discharge
Technical difficulty with procedureAccidental puncture or laceration during procedureAll medical and surgical dischargesObstetric discharge
Transfusion reactionSecondary diagnosis of transfusion reactionAll medical and surgical dischargesNone
Birth trauma—injury to neonateIntracranial hemorrhage, extraclavicular fracture, spinal injury, nerve injury (other than facial and brachial plexus), other birth traumaAll live birthsPreterm infants (for intracranial hemorrhage), osteogenes is imperfecta (for fracture)
Obstetric trauma—vaginal with instrumentationPrincipal or secondary diagnosis of fourth-degree perineal, high vaginal, or cervical laceration or procedure to repair any of these lacerationsAll vaginal deliveries with forceps or vacuumNone
Obstetric trauma—vaginal without instrumentationSame as aboveAll vaginal deliveries without forceps or vacuumNone
Obstetric trauma—cesareanSame as above plus uterine or urinary tract laceration or procedure to repair any of these lacerationsAll cesarean deliveriesNone
  • All diagnosis-based numerator definitions are based on secondary diagnoses unless otherwise noted. More details on these indicators are available at