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Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate (PSI15)

CBE ID
0345
1.4 Project
Patient Safety
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Fall 2019
Is Under Review
No
1.3 Measure Description

Accidental punctures or lacerations (secondary diagnosis) per 1,000 discharges for patients ages 18 years and older who have undergone an abdominopelvic procedure; in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. Excludes cases with accidental puncture or laceration as a principal diagnosis, cases with accidental puncture or laceration as a secondary diagnosis that is present on admission, and obstetric cases.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report events per 1,000 hospital discharges.]

    • 1.14 Numerator

      Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with:
      • Any secondary ICD-10-CM diagnosis codes for accidental puncture or laceration during a procedure (TECHI15D); and
      • A second abdominopelvic procedure (ABDOMI15P) =>1 day after an index abdominopelvic procedure (ABDOMI15P).

    • 1.15 Denominator

      Surgical (Appendix E: SURGI2R) and medical discharges (Appendix C: MEDIC2R), for patients ages 18 years and older with any ICD-10-PCS procedure code for an abdominopelvic procedure (ABDOMI15P).

    • Exclusions

      Exclude cases:
      • with a principal ICD-10-CM diagnosis code for accidental puncture or lacerations during a procedure (TECHNI15D),
      • secondary diagnosis present on admission for accidental puncture or laceration during a procedure (TECHNI15D), among patients otherwise qualifying for the numerator
      • MDC 14 (pregnancy, childbirth, and puerperium) assigned to the discharge
      • with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), or principal diagnosis (DX1=missing)

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Patient Safety Fall Cycle 2019
      Initial Endorsement
      Last Updated
      Removal Date