Patient Safety

Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time

Percentage of patients who died with documented or undocumented complications within 30 days from admission

Percentage of patients who died with documented or undocumented complications in the hospital

All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

(Total number of injury falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

In-hospital deaths per 1,000 hospital discharges with gastrointestinal hemorrhage as a principal diagnosis for patients age 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[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 in-hospital deaths per 1,000 hospital discharges.]

The rate of hypoglycemic events following the administration of an anti-diabetic agent

Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical or medical discharges for patients ages 17 years and younger. Excludes normal newborns; neonates with a birth weight less than 500 grams; cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic surgery repair or cardiac surgery; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

The inappropriate diagnosis of CAP in hospitalized medical patients (or “Inappropriate Diagnosis of CAP”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for CAP who do not meet diagnostic criteria for pneumonia (thus are inappropriately diagnosed and treated).