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Patient Safety

Intensive Care Unit Venous Thromboembolism Prophylaxis

  • This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

    CBE ID
    0372

Medication Reconciliation Post-Discharge

  • The percentage of discharges from January 1–December 1 of the measurement year for patients 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 days total).

    CBE ID
    0097

Nursing Hours per Patient Day

  • NSC-13.1 (RN hours per patient day) – The number of productive hours worked by RNs with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    NSC-13.2 (Total nursing care hours per patient day) – The number of productive hours worked by nursing staff (RN, LPN/LVN, and UAP) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month.

    Measure focus is structure of care quality in acute care hospital units.

    CBE ID
    0205

PACE Participant Fall Rate

  • The quarterly incidence rate of falls amongst PACE participants per 1,000 participant days.

    CBE ID
    3001

PACE-Acquired Pressure Ulcer/Injury Prevalence Rate

  • Prevalence of PACE-acquired pressure ulcers/injuries (Stages 3, 4, unstageable, and deep tissue injury) among PACE participants in a quarter, expressed as persons with 1 or more pressure ulcers/injuries divided by the number of participants on the PACE organization’s census who resided in a home setting (home or assisted living facility)for at least one day during the quarter.

    CBE ID
    3000

Participation in a Systematic National Dose Index Registry

  • Participation in a multi-center, standardized data collection and feedback program that will establish national dose index benchmarks for designated examinations. The registry will eventually provide a comparison of practice or facility dose indices such as CTDIvol and DLP for specified examinations relative to national and regional benchmarks. Data is captured electronically from the images of CT examinations using Digital Imaging and Communications in Medicine (DICOM) standards and the Integrating the Healthcare Enterprise (IHE) Radiation Exposure Monitoring (REM) profile.

    CBE ID
    0740

Patient Fall

  • Percentage of ASC admissions experiencing a fall in the ASC.

    CBE ID
    0266