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Patient Safety - Indicators


This section displays our rates for patient falls, pressure ulcers ("bed sores"), and the use of restraints. Norton Healthcare performance represents the performance of all the hospitals combined.

Patient falls per 1000 inpatient days, by unit
Number of patients in a critical care unit (per 1000 patient days) who fell with or without injury. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF HC 19 / ANA CalNOC) ICU low 0.59 1.91 1.11 0.97 0.26 0.89    
Number of patients in a step down unit (per 1000 patient days) who fell with or without injury. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF HC 19 / ANA CalNOC) StepDown low 4.55 4.20 4.11 4.43   4.28    
Number of patients in a medical/surgical (Med-Surg) unit (per 1000 patient days) who fell with or without injury. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF HC 19 / ANA CalNOC) Med-Surg low 3.88 2.61 3.72 3.00 1.44 3.24    
Number of patients in a medical unit (per 1000 patient days) who fell with or without injury. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF HC 19 / ANA CalNOC) Medical low         2.09 2.09    
Number of patients in a surgical unit (per 1000 patient days) who fell with or without injury. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF HC 19 / ANA CalNOC) Surgical low       #   #    
Patient falls with injury per 1000 inpatient days, by unit
Number of patients in a critical care unit (per 1000 patient days) who had a fall resulting in an injury. Excludes injuries with unknown severity. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF NS 3 / NQF HC 19 / ANA) ICU low 0Quality Ribbon 0.24 0.07 0Quality Ribbon 0Quality Ribbon 0.05    
Number of patients in a step down unit (per 1000 patient days) who had a fall resulting in an injury. Excludes injuries with unknown severity. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF NS 3 / NQF HC 19 / ANA) StepDown low 1.01 0.70 0.81 2.13   1.06    
Number of patients in a medical/surgical (Med-Surg) unit (per 1000 patient days) who had a fall resulting in an injury. Excludes injuries with unknown severity. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF NS 3 / NQF HC 19 / ANA) Med-Surg low 1.06 0.68 0.97 0.50 0.15 0.79    
Number of patients in a medical unit (per 1000 patient days) who had a fall resulting in an injury. Excludes injuries with unknown severity. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF NS 3 / NQF HC 19 / ANA) Medical low         0.52 0.52    
Number of patients in a surgical unit (per 1000 patient days) who had a fall resulting in an injury. Excludes injuries with unknown severity. Excludes visitors, students, staff members and patients that were not on the unit at the time of the fall (e.g., fall in radiology department).(NQF NS 3 / NQF HC 19 / ANA) Surgical low       #   #    
Restraints - percent of inpatients with restraint use, by unit
Number of patients in a critical care unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) ICU low 22.00 23.53 16.55 10.71 2.41 15.48    
Number of patients in a step down unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) StepDown low 1.44 1.22 0.55 0.71   0.88    
Number of patients in a medical/surgical (Med-Surg) unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) Med-Surg low 0Quality Ribbon 0Quality Ribbon 0.52 0Quality Ribbon 0Quality Ribbon 0.08    
Number of patients in a medical unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) Medical low         0Quality Ribbon 0Quality Ribbon    
Number of patients in a surgical unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) Surgical low       #   #    
Number of patients in a moderate acuity unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study. Excludes patients less than 18 years of age.(NQF NS 4 / CalNOC) Moderate Acuity low         0Quality Ribbon 0Quality Ribbon    
Number of patients in a NICU unit per 100, who received vest and/or limb restraint(s), (upper, lower or both) as recorded on a one-day study.(NQF NS 4 / CalNOC) Neonatal ICU low         0Quality Ribbon 0Quality Ribbon    
Pressure ulcers stage II+ - percent of inpatients, by unit
Number of patients in a critical care unit per 100, who had a hospital acquired pressure ulcer stage II or greater (bed sore) as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) ICU low 2.70 2.38 3.45 0Quality Ribbon 6.02 3.32    
Number of patients in a step down unit per 100, who had a hospital acquired pressure ulcer (bed sore) stage II or greater as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) StepDown low 2.70 0Quality Ribbon 0.55 0Quality Ribbon   0.99    
Number of patients in a medical/surgical (Med-Surg) unit per 100, who had a hospital acquired pressure ulcer (bed sore) stage II or greater as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) Med-Surg low 0.23 0.58 1.05 0Quality Ribbon 0Quality Ribbon 0.34    
Number of patients in a medical unit per 100, who had a hospital acquired pressure ulcer (bed sore) stage II or greater as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) Medical low         1.37 1.37    
Number of patients in a surgical unit per 100, who had a hospital acquired pressure ulcer (bed sore) stage II or greater as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) Surgical low       #   #    
Number of patients in a moderate acuity unit per 100, who had a hospital acquired pressure ulcer (bed sore) stage II or greater as recorded on a one-day study. Excludes patients less than 18 years of age, ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) Moderate Acuity low         0Quality Ribbon 0Quality Ribbon    
Number of patients in a neonatal intensive care unit per 100, who had a hospital acquired pressure ulcer stage II or greater (bed sore) as recorded on a one-day study. Excludes ulcers less than stage II, pressure ulcers present at the time of admission, and patients for whom an exam is inappropriate because they are critical or dying.(NQF NS 2 / CalNOC) Neonatal ICU low         0.69 0.69    
Miscellaneous - percent of inpatients
Number of patients who had a length of stay of at least 5 days per 100 who developed a pressure ulcer (bed sore) while in the hospital. Risk-adjusted for age, sex, DRG, and comorbidity categories. Excludes patients with diseases of the skin, subcutaneous tissue and breast, hemiplegia, paraplegia, quadriplegia, obstetrical patients, and patients admitted from a long-term care facility.(AHRQ PSI 3) developing in-hosp pressure ulcer (AHRQ) low 0Quality Ribbon 0.1 0.0 0.1   0.0   0.4
Number of inpatients with low mortality diagnoses per 100 who died. This indicator identifies in-hospital deaths among patients that are considered unlikely to die in the hospital. Includes inpatients in DRGs with less than 0.5% mortality based on National Inpatient Sample 1997. Excludes patients with any code for trauma, immunocompromised state, or cancer.(AHRQ PSI 2) in low-mortality DRGs who die low 0Quality Ribbon 0Quality Ribbon 0.03 0.03   0.02   0.03
Number of surgery patients who developed selected complications during their hospitalization per 100 who died in the hospital. This indicator is sometimes called ?failure to rescue? and is believed to be sensitive to nurse staffing. The indicator does not work well in a pediatric population. No U.S. data are available for this indicator, so we have compared ourselves to the Kentucky average. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients with complications (i.e., pneumonia, DVT/PE, sepsis, acute renal failure, shock/cardiac arrest, or GI hemorrhage/acute ulcer). Excludes patients 75 years and older, neonates and newborns, patients transferred to or from an acute care facility, or patients admitted from a long-term care facility. Other exclusion criteria are specific to each complication.(AHRQ PSI 4) w/ select complications who die - surgical inpatients low 8.9 19.1 14.5 13.2   13.4   12.4
Miscellaneous - # of inpatients (volume indicator)
Number of inpatients with blood transfusion , who had a blood transfusion reaction. Excludes patients with principal diagnosis of blood transfusion reaction.(AHRQ PSI 16) # of inpatients w/ a blood transfusion reaction low 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon   0Quality Ribbon    

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