Struggling with Patient Safety Indicators? Help is Coming Your Way

A four-part series on PSIs is being produced by ICD10monitor and Talk Ten Tuesdays in cooperation with ChristianaCare.

I bet some of you reading this article were not even born or were just youngsters when the Institute of Medicine report To Err is Human: Building a Safer Health System was released.

The report had been released early because it had been leaked and there were fears that the media was going to sensationalize the details. Studies had revealed that somewhere between 50,000 and 100,000 people succumbed each year as a result of medical errors.

More people were found to die annually from adverse events than from motor vehicle collisions, breast cancer, or AIDS. Besides the human toll, the financial costs of these medical errors were staggering. More recent estimates of medical errors have been in the range of 250,000 deaths annually, representing the third leading cause of death in the United States.

Safety was defined in the report as freedom from accidental injury. Not all errors result in harm, like a patient who needs potassium supplementation accidentally receiving 40 mEq instead of 20 mEq. It was not the correct amount ordered, but it was not so excessive as to cause a problem.

Errors which result in harm or injury are defined in the report as adverse events, but not all adverse events are avoidable. The study was intended to identify which adverse events are preventable and how to implement strategies that address medical error at the systemic level. Another fascinating exploration into medical errors which upended medical practice for the good is The Checklist Manifesto, by Atul Gawande. I highly recommend reading this one, too.

The report culminated in multiple recommendations including creating a Center for Patient Safety within the Agency for Healthcare Research and Quality (AHRQ). Systems for reporting and monitoring the occurrence of errors were established, and programs which established performance standards and expectations for healthcare organizations and professionals focused on patient safety.

One of the programs set in place was the Patient Safety Indicator (PSI) metrics. PSIs were intended to identify potentially avoidable safety events which represent opportunity to improve healthcare delivery. They primarily deal with in-hospital complications, and the majority are related to procedural or operative interventions, including obstetrical ones. The versions are now being denoted with the year, so if you are looking for the current specifications be sure that you are using version 2022 (

I strongly recommend that institutions strive for zero occurrence, but it is not realistic to expect that incidence can actually be zero. Even under the best circumstances, with the most meticulous prevention, stuff happens. It is very useful to peruse the benchmark tables and compare your rate to the observed rates derived from the HCUP, or Healthcare Cost and Utilization Project, data. If your hospital’s rate greatly exceeds the published benchmark rates, your organization may benefit from a closer inspection of that PSI and derivation of a preventative program.

I strongly recommend that organizations investigate PSIs with the intent of identifying opportunities for improving patient care and for ways to decrease the incidence of potentially preventable adverse events. Too often I see institutions performing intricate clinical documentation contortions to make it appear as though PSIs have not occurred, rather than analyzing root causes and eliminating system processes which enable these PSIs to occur. If a postoperative wound dehiscence rate is too high, the answer may not be to conjure up exclusion criteria, but instead to have the culpable surgeon wash their hands better.

In August of this year, I received a question from Alicia regarding PSI 04, which is Death Rate among Surgical Inpatients with Serious Treatable Complications. This was not a PSI which I collaborated on with my Quality department when I was a physician advisor, so I turned to my LinkedIn community to see if any of my connections had experience and advice on this specific PSI. Dr. James Kennedy gave us some insight about a month ago, and we were delighted to have Dr. Raj Subbiah from ChristianaCare also offering up his organization’s expertise.

Therefore, we are embarking on a four-part series here in ICD10Monitor and on Talk Ten Tuesdays concentrating on Patient Safety Indicators. The professionals from ChristianaCare are going to detail how they built a multidisciplinary PSI review team and give us specific insight into multiple PSIs including PSI 04, PSI 90, and some other individual PSIs.

Please tune in and give Dr. Jennifer Brettler and Ms. Kimberly Seery a warm Talk Ten Tuesday welcome. Feel free to send in questions to cbuck@medlearnmedia.comand we will try to address as many as we can.

Programming note: Listen to Dr. Erica Remer live today when she cohosts Talk Ten Tuesday with Chuck Buck at 10 Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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