National Healthcare Safety Dashboard

Patient Safety Indicators (PSIs) are derived from hospital discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). The unit of analysis is the hospital discharge (i.e., the hospital inpatient stay), not a person or patient. Thus a person admitted to the hospital multiple times in one year is counted each time as a separate discharge from the hospital. The unit of analysis depends on the measure (see notes below each figure and refer to the technical documentation for full details).

The PSI estimates are derived using the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) beginning with the 2016 data year. The derivations are done using the AHRQ Patient Safety Indicators Version 2022. These data are collected annually from 48 states and the District of Columbia. The AHRQ HCUP SID contain the universe of discharges from all nonfederal acute care hospitals in participating states in the Healthcare Cost and Utilization Project (HCUP). Visit HCUP-US and HCUP SID documentation for more information.

Estimates are weighted to be nationally representative. The specific hospital patient population represented depends on the Patient Safety Indicator (PSI) measure. Refer to the Technical Specifications for Patient Safety Indicators Version 2022 documentation for detailed inclusion/exclusion criteria.

A measure is suppressed when the reporting cell draws from fewer than 2 hospitals, contains fewer than 11 discharges, or has a relative standard error (standard error / weighted estimate) greater than 0.30 or equal to 0.

Note that small differences in measure estimates may not be clinically meaningful, given the relative rarity of outcomes examined and the power to detect differences with the large number of records in the HCUP databases.

The dashboard uses the v2022 PSI software, which excludes all discharges with COVID-19.

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

The Quality and Safety Review System (QSRS) is designed to identify the occurrence of specified adverse events (AEs) to gain a better understanding of patient safety in the hospital setting. QSRS data are collected through retrospective abstraction of inpatient records. Each month, a predetermined number of records is requested from randomly selected hospitals. These records are abstracted by the Centers for Medicare & Medicaid Services (CMS) Clinical Data Abstraction Center (CDAC) using the QSRS’s standardized specifications to ensure AEs are reliably identified across all hospitals.

Based on these abstractions, QSRS determines whether any of the specified AEs occurred during that particular hospital stay. Within a given AE, abstractors are instructed to only report the highest severity event. As such, while QSRS may show that multiple, different AEs occurred during a single hospital stay (e.g., a fall and hospital-acquired pneumonia), it would not show two or more of the same AE for the same patient during a single hospitalization (e.g., two or more falls).

This dashboard highlights two composite rates: the rate of patients experiencing at least one AE identified by QSRS during their stay and the total number of AEs per 1,000 discharges. The rate of patients experiencing at least one AE identified by QSRS during their stay is calculated by taking the number of hospitalizations with at least one AE, dividing it by the total number of discharges, and multiplying that by 100. The total number of AEs per 1,000 discharges is calculated by taking the total number of identified AEs, dividing by the total number of discharges, and multiplying this number by 1,000. These rates are weighted to provide national estimates for the occurrence of the specified in-hospital AEs among the Medicare population.

For detailed information on calculation of AE rates, weighting, and AE specifications, refer to Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report.

Agency for Healthcare Research and Quality. Data displayed from the Quality and Safety Review System (QSRS). January 1, 2021, through December 31, 2022.

The current sample of records is designed to focus on acute care inpatient facilities receiving technical assistance from the CMS Quality Innovation Network Quality Improvement Organizations (QIO) Program under the 12th Scope of Work. These include five cohorts: Medicare Rural Acute Care Hospitals participating in the Inpatient Prospective Payment System (IPPS), Medicare Targeted Urban Acute Care Hospitals participating in IPPS, Medicare Other Acute Care Hospitals participating in IPPS, Critical Access Hospitals, and Indian Health Service (IHS) hospitals. Records from IHS hospitals are not included in the analyses presented on this dashboard because IHS hospitals are sampled differently than the hospitals in all other cohorts.

For the included hospital cohorts, CMS sampling was multistage, performed at the hospital level and randomly at the patient level for all patients 18 years and older insured by Medicare. The QSRS sample is disproportionately distributed with respect to age. Patients ages 18-64 years represent only about 15 percent of the sample. These patients likely reflect dually eligible beneficiaries, enrolled in both Medicare and Medicaid who are eligible by virtue of their age or disability and low incomes. The patients are a diverse population that includes people with multiple chronic conditions, physical disabilities, mental illness, and cognitive impairments such as dementia and developmental disabilities, as well as patients that are relatively health compared with Medicare-only patients.

More information on sample characteristics and sampling methodology can be found in the QSRS report Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report.

This dashboard excludes estimates for specific AE types and AEs where the population at risk was lower than 1,000, but the measures are included in Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report. Due to the resource-intensive nature of record abstraction and predefined cohorts, obtaining a sample large enough to detect rare events may not always be feasible for QSRS. QSRS findings should not be interpreted as reflecting all possible AEs that may have occurred during the reviewed hospital stays. Additional possible AEs may not be accounted for in the system, such as those that are not compatible with the abstraction method used in QSRS and those that would not be discernible from review of the inpatient hospitalization record (e.g., those that manifested after the patient was discharged).

These findings may not be representative of, and should not be extrapolated to, the entire population of patients hospitalized in the United States. Per the sampling methodology defined by CMS, selection of records was limited to those patients insured by Medicare. As such, occurrence of the AEs specified in QSRS may be different among patients with other insurance types. In addition, there are no records from patients under 18, who also may experience adverse events differently than the adult Medicare population. While demographic information about the patient population is available in QSRS data, the rates displayed have not been adjusted to reflect patient characteristics or other potential confounding variables.

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

Uncertainty estimates for the rate of patients experiencing at least one AE identified by QSRS during their stay are calculated using the Wald confidence interval method, which differs from previous published reports that used the Wilson confidence interval method. Uncertainty estimates for the total number of AEs per 1,000 discharges shown are calculated using the Poisson regression. Therefore, confidence intervals shown may differ from other QSRS publications.

Methodology

Data are collected from inpatient locations where denominator data can be collected, which can include critical/intensive care units; specialty care areas; neonatal units, including neonatal intensive care units; and step-down units, wards, and long-term acute care units. A complete list of inpatient locations and instructions for mapping can be found in the Centers for Disease Control and Prevention (CDC) Locations and Descriptions chapter. This information includes reporting of denominator data (patient days and central-line days). CLABSI surveillance after patient discharge from a facility is not required.

National Healthcare Safety Network (NHSN) users reporting CLABSI data to the system must adhere to the definitions and reporting requirements for CLABSIs as specified in the NHSN Patient Safety Component Protocol.

Data Source

CDC/NHSN requires that data be submitted on a monthly basis and strongly encourages healthcare facilities to enter each month’s data within 30 days of the end of the month in which they are collected (for example, all March data should be entered by April 30), to have the greatest impact on infection prevention activities. However, for purposes of fulfilling Centers for Medicare & Medicaid Services (CMS) quality measurement reporting requirements, each facility’s data must be entered into NHSN no later than 4- 1/2 months after the end of the reporting quarter. In other words, Q1 (January/February/March) data must be entered into NHSN by August 15, Q2 must be entered by November 15, Q3 must be entered by February 15, and Q4 must be entered by May 15 for data to be shared with CMS. CDC will provide CLABSI standardized infection ratios for each reporting hospital by CMS Certification Number.

Data are from the Provider Data Catalog.

Population Represented

Data are collected from inpatient locations where denominator data can be collected, which can include critical/intensive care units; specialty care areas; neonatal units, including neonatal intensive care units; and step-down units, wards, and long-term acute care units. A complete list of inpatient locations and instructions for mapping can be found in the CDC Locations and Descriptions chapter.

Limitations

Critical access hospitals are excluded from the Hospital-Acquired Condition Reduction Program (HACRP) process per requirement HCBM-697. The process shall exclude the following non-Inpatient Prospective Payment System hospitals from calculations for the HACRP:

• Critical Access Hospitals (CAH)
• U.S. Territories
• Puerto Rico (a U.S. Territory)
• PPS-Exempt Cancer Hospitals
• Veterans Affairs Hospitals
• Children’s Hospitals
• Long-Term Care Hospitals (LTCHs)
• Psychiatric Hospitals and Units
• Rehabilitation Hospitals and Units
• Religious Non-Medical Health Care Institutions
• Rural Emergency Hospitals (REH)

Note: the methodology, data source, and population represented in the data set are unique to this dashboard. Please consider this context when reviewing the dashboards, to prevent making comparisons across datasets.

Methodology

Surveillance may occur in any inpatient locations where denominator data can be collected. Neonatal intensive care units may participate but only off plan (not as part of their monthly reporting plan). A complete list of inpatient locations and instructions for mapping are located in the CDC Locations and Descriptions chapter.

Postdischarge surveillance for CAUTI is not required. However, if a postdischarge CAUTI is discovered, any CAUTI with a date of event on the day of discharge or the next day is attributable to the discharging location and should be included in any CAUTI reported to NHSN for that location (see Chapter 2, Transfer Rule).

Data Source

NHSN users reporting CAUTI data to the system must adhere to the definitions and reporting requirements for CAUTIs as specified in the NHSN Patient Safety Component Protocol. This information includes reporting of denominator data (patient days and urinary catheter days), as well as symptomatic urinary tract infections and asymptomatic bacteremic urinary tract infections that are catheter associated. Specifically, it refers to cases in which the patient has an indwelling urinary catheter in place for more than 2 calendar days on the date of the event (with the date of device placement being day 1) and an indwelling urinary catheter in place on the date of the event or the day before. CAUTI data must be reported from each patient care location in which facilities are required to monitor and report CAUTIs.

CDC/NHSN requires that data be submitted on a monthly basis and strongly encourages healthcare facilities to enter each month’s data within 30 days of the end of the month in which they are collected (for example, all March data should be entered by April 30), to have the greatest impact on infection prevention activities. However, for purposes of fulfilling CMS quality measurement reporting requirements, each facility’s data must be entered into NHSN no later than 4-1/2 months after the end of the reporting quarter. In other words, Q1 (January/February/March) data must be entered into NHSN by August 15, Q2 must be entered by November 15, Q3 must be entered by February 15, and Q4 must be entered by May 15 for data to be shared with CMS. CDC will provide CAUTI standardized infection ratios for each reporting hospital by CMS Certification Number.

Data are from the Provider Data Catalog.

Population Represented

Data are collected from inpatient locations where denominator data can be collected, which can include critical/intensive care units and neonatal intensive care units.

Limitations

CAH hospitals are excluded from the Hospital-Acquired Condition Reduction Program (HACRP) process per requirement HCBM-697:
The process shall exclude the following non-IPPS hospitals from calculations for the HACRP:

• Critical Access Hospitals (CAH)
• U.S. Territories
• Puerto Rico (a U.S. Territory)
• PPS-Exempt Cancer Hospitals
• Veterans Affairs Hospitals
• Children’s Hospitals
• Long-Term Care Hospitals (LTCHs)
• Psychiatric Hospitals and Units
• Rehabilitation Hospitals and Units
• Religious Non-Medical Health Care Institutions
• Rural Emergency Hospitals (REH)

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

Methodology

Data are on all surgical patients in any inpatient facility or hospital outpatient procedure department where the selected NHSN operative procedures are performed. Once procedure (denominator) and surgical site infection (numerator) data are collected and entered into NHSN, the data can be analyzed/visualized in various ways, including with descriptive analysis reports and standardized infection ratio reports (see resources for the NHSN Standardized Infection Ratio (SIR)).

Data Source

NHSN requires data submission on a monthly basis and strongly encourages healthcare facilities to enter each month’s data within 30 days of the end of the month in which they are collected (for example, all March data should be entered by April 30). For purposes of fulfilling CMS quality measurement reporting requirements, each facility’s data must be entered into NHSN no later than 4-1/2 months after the end of the reporting quarter. In other words, Q1 (January/February/March) data must be entered into NHSN by August 15, Q2 (April/May/June) must be entered by November 15, Q3 (July/August/September) must be entered by February 15, and Q4 (October/November/December) must be entered by May 15 in order for NHSN to report to CMS.

Surgical site infection (SSI) surveillance data may be reported to NHSN in a number of ways. Numerator data may be reported to NHSN by manual data entry into the NHSN web-based application or via clinical document architecture (CDA) file format. Denominator data may be reported by manual data entry, CDA, or ASCII comma-delimited text file. For the file format refer to Importing Patient Safety Procedure Data specifications.

NHSN will risk adjust SSI data reported to CMS, using the complex 30-day SSI risk models described in the NHSN SIR Guide. NHSN will provide hospital-specific SSI standardized infection ratios, one for HYST and one for COLO, for each reporting hospital by CMS Certification Number.

Data are from the Provider Data Catalog.

Population Represented

All surgical patients in any inpatient facility or hospital outpatient procedure department where the selected NHSN operative procedures are performed.

Limitations

Critical access hospitals are excluded from the Hospital-Acquired Condition Reduction Program (HACRP) process per requirement HCBM-697:

The process shall exclude the following non-IPPS hospitals from calculations for the HACRP:

• Critical Access Hospitals (CAH)
• U.S. Territories
• Puerto Rico (a U.S. Territory)
• PPS-Exempt Cancer Hospitals
• Veterans Affairs Hospitals
• Children’s Hospitals
• Long-Term Care Hospitals (LTCHs)
• Psychiatric Hospitals and Units
• Rehabilitation Hospitals and Units
• Religious Non-Medical Health Care Institutions
• Rural Emergency Hospitals (REH)

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

Methodology

The CMS Patient Safety Indicators (PSIs), including CMS PSI 04 Death Rate Among Surgical Inpatients With Serious Treatable Conditions, are derived annually from subsection (d) hospital discharge records from Medicare fee-for-service (Part A) claims and similar records from Veterans Affairs hospitals. The unit of analysis for CMS PSI 04 is in-hospital deaths per 1,000 surgical discharges with serious treatable complications during the 24-month discharge period. Refer to the technical documentation for full details.

Data Source

The CMS PSI 04 estimates are derived using Medicare fee-for-service (Part A) claims. These data are collected annually from (a) hospitals paid under the Inpatient Prospective Payment System and (b) Maryland hospitals because these are the only hospitals required to report present on admission data for each diagnosis code in the International Classification of Diseases, 10th Revision, Clinical Modification. For more information about CMS PSI 04, refer to resources such as the FAQ document and technical specifications available on the QualityNet website.

Data are from the Provider Data Catalog.

Population Represented

The CMS PSI 04 uses data for Medicare fee-for-service and Veterans Affairs patients. Records were excluded if the discharge date was not within the period of interest, if the total length of stay was greater than 365 days, if the Medicare beneficiary was enrolled in a Medicare Advantage (Part C) plan at the time of hospital discharge, or if necessary data elements were missing or inconsistent (i.e., the admission type was “newborn,” key data elements were missing, or the dates of service and discharge disposition were inconsistent with the beneficiary’s vital status, according to the Medicare enrollment file). The technical documentation includes detailed inclusion/exclusion criteria.

Limitations

A measure is suppressed when the hospital has fewer than 25 eligible discharges.

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

Additional Notes

No facility is expected to have a zero rate for PSI 04 because it targets rescue from severe conditions that have a nonzero death rate. For more information on PSI 04, including literature references, see several related FAQs at the AHRQ Quality Indicators site.

Methodology

The risk-standardized complication measure for elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) assesses complications including infection, heart attack, pneumonia, wounds that split open or bleed after surgery, serious blood clots, replacement hip/knee joints that do not work, and death. The hip/knee complication measure includes distinct hospitalizations of patients undergoing elective, primary THA/TKA procedures from the most recent 3-year period from April to March.

The risk adjustment models involve a two-step process to assess whether a patient has a risk factor: (1) using inpatient, outpatient, and physician Medicare administrative claims data extending 12 months (may be less than 12 months of claims data available due to Extraordinary Circumstances Exception) prior to the index admission, and (2) assessing if clinical risk factors are present on admission during the patient’s index stay.

The technical documentation has more details.

Data Source

The hip/knee replacement complication rate is calculated using claims from Medicare fee-for-service patients as well as Veterans Health Administration (VHA) administrative data. Beneficiaries enrolled in Medicare managed care plans are not included.

Data are from the Provider Data Catalog.

Population Represented

The hip/knee replacement complication rate includes Medicare or VHA beneficiaries age 65 years or older who were electively admitted to an eligible short-term acute care hospital (or Veterans Affairs hospital) for primary total hip or knee replacement. For non-VHA beneficiaries, it includes people enrolled in original Medicare (traditional fee-for-service Medicare). Patients undergoing revisions or with hip, femur, or pelvic fractures or bony metastases or requiring hardware removal are not eligible. Patients who left against medical advice, were transferred, had more than two total hip or total knee replacements performed during the same hospitalization, or had COVID-19 at admission are excluded. If a patient has multiple admissions in the same year (April to March), only one admission is counted. The technical documentation provides detailed inclusion/exclusion criteria.

Limitations

Due to the COVID-19 pandemic, CMS has excluded all data from January 2020 through June 2020 from its measures. Changes to the measure specifications need to be taken into consideration when comparing the national rates over time.

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

Additional Notes

Total hip/total knee replacement procedures have been shifting from the inpatient setting to the outpatient setting.

Methodology

The SEP-1 measure is manually abstracted from the medical record based on requirements included in the data elements. The unit of analysis is the hospital discharge (i.e., the hospital inpatient stay), not a person or patient.  Thus, a person admitted to the hospital multiple times in one year is counted each time as a separate discharge from the hospital. Further details are in the specifications manual: Hospital Inpatient Specifications Manuals..

Data Source

Because this measure is manually abstracted, retrospective data sources for required data elements include hospital administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest.
Complete documentation includes the principal or other diagnosis and procedure codes in the International Classification of Diseases, 10^th Revision, Clinical Modification, which require retrospective data entry. Further details are available for download: Hospital Inpatient Specifications Manuals.

Data are from the Provider Data Catalog.

Population Represented

Included Populations: Discharges for adults age 18 and over with a principal or other diagnosis code of sepsis, severe sepsis, or septic shock in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

Excluded Populations include:

• Patients with an ICD-10-CM principal or other diagnosis code of U07.1 (COVID-19).
• Patients with a directive for comfort care or palliative care within 6 hours of presentation of severe sepsis.
• Patients with a directive for comfort care or palliative care within 6 hours of presentation of septic shock.
• Administrative contraindication to care within 6 hours of presentation of severe sepsis.
• Administrative contraindication to care within 6 hours of presentation of septic shock.
• Length of stay >120 days.
• Transfer in from another acute care facility.
• Patients enrolled in a clinical trial for sepsis, severe sepsis, or septic shock treatment or intervention.
• Patients with severe sepsis who are discharged within 6 hours of presentation.
• Patients with septic shock who are discharged within 6 hours of presentation.

These details be found in v5.17 of the specifications manual at Hospital Inpatient Specifications Manuals.

Limitations

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.

The SOPS Hospital Survey 2.0 (HSOPS 2.0) evaluates patient safety culture in hospitals. Patient safety culture is the extent to which beliefs, values, and norms support and promote patient safety. That is, determining what is rewarded, supported, expected, and accepted in an organization as it relates to patient safety.

Additional details about the measure definitions, methodology, and other information are in the HSOPS 2.0 reports, including the Hospital Survey 2.0: 2021 User Database Report and Hospital Survey 2.0: 2022 User Database Report.

HSOPS 2.0 data are typically updated every 2 years. Database year 2021 includes data collection from November 1, 2018, through October 31, 2020. Database year 2022 includes data collection from November 1, 2020, through July 31, 2022.

Results are unweighted average hospital-level percent positive scores. Hospital-level percent positive scores are the percentages of healthcare providers and staff within a hospital who answered positively (e.g., Strongly Agree/Agree). Higher values indicate better patient safety culture (scores are the percentages of most positive responses).

Data Source: Data are from the Agency for Healthcare Research and Quality, Surveys on Patient Safety Culture Hospital 2.0 Database.

Contact Information: databasesonsafetyculture@westat.com.

The HSOPS 2.0 sample is composed of healthcare providers and staff working in hospitals that chose to administer the HSOPS survey instrument and voluntarily submit to the HSOPS 2.0 Database.
For additional information on hospital and respondent characteristics, refer to:

• Hospital 2.0 Survey 2021 Database Report
• Hospital 2.0 Survey 2022 Database Report

The survey sample is voluntary, so results are not from a nationally representative sample. Therefore, results should not be interpreted or extrapolated to the entire population of U.S. hospitals.

Scores in the 2021 and 2022 databases may have been affected by the COVID-19 pandemic.

Note: The methodology, data source, and population represented in the dataset are unique to this dashboard. Consider this context when reviewing the dashboards, to avoid making comparisons across datasets.