Quality care Indicators

Anesthesiology
Aspiration of gastric contents with development of typical X-ray
findings of aspiration pneumonia's related to anesthesia care
Cardiac arrest related temporally to anesthesia care
Clinically apparent acute myocardial infarction related temporally
to anesthesia care
Dental injury during anesthesia care
Development of a peripheral neurologic deficit related temporally
to anesthesia care
Development of injury to the brain or spinal cord related temporally
to anesthesia care
Development of post-dural puncture headache related to anesthesia
care
Equipment failure/malfunction/disconnection
Failed intubation
Failed regional anesthesia requiring induction of general anesthesia
Failure to emerge from general anesthesia within a specified time
Fulminant pulmonary edema related temporally to anesthesia care
Ordered labs not done
Patient injury/accident
Patient handling/support policy breakdown
Patient stuck more than two times for blood test
Perforation during barium enema
Pneumothorax following invasive procedure
Poor quality in portable film
Post myelogram headache (requiring intervention)
Repeat procedure because of unsatisfactory result(s)
Reported data not acted upon
Seizure within less than 24 hours of procedure
Single unit transfusion
Tubes or samples unlabeled
Unauthorized examination
Unreported data that adversely affect patient care
Wrong data reported
Wrong examination done on patient
Wrong study ordered
X-ray results not in chart
Medical/ Surgical
Discharged against medical advice
Drug or transfusion reaction
Hospital/OR-incurred incident
Operation for removal of foreign body left in operative site
Postoperative complication
Repeat invasive diagnostic procedure during same admission
Unplanned removal or repair of normal body part during surgery
(without consent)
Nursing Care/Support Occurrences
Cancelled procedure or therapy because of improper patient prep
Cardiac/respiratory arrest
Mch care

Intrauterine fetal death (less than 20 weeks delivered on labor

deck)
Maternal death
Maternal insulin-controlled diabetes
Midforceps delivery
Neonatal death
Neonatal mortality in high-risk infants at institutions with NICUs
Neonatal sepsis
Newborn weight of less than 2,000 grams
Newborn weight of less than 2,500 grams
Newborn weight of more than 4,500 grams
Other (pre-term infant)
Perinatal mortality in the absence of extreme prematurity
Postpartum hemorrhage
Postpartum infection
Precipitous delivery
Pre-eclampsia
Premature infant delivered by elective repeat caesarean section
Primary caesarean section for failure to progress
Primary caesarean section
(Review if none of the following criteria are found in record:)
Placenta previa
CPD
Failure to progress
Fetal distress
Active herpes
Breech presentation
Pre-eclampsia
Stillborn
Maternal death
Apgar score of 6 or less at 5 minutes
Prolonged length of stay on maternal indications following either
vaginal delivery or caesarean section
Rates of attempted and successful "VBACs"
Resuscitation with intubation of a term infant
Failure to respond to therapy
Hospitalized within 48 hours of ER visit
Illegible handwriting
Improper processing/diagnosing/treating of patient with VD
Inadequate follow-up or untimely referral
Inappropriate delay in seeing patient with acute illness/acute distress
Incomplete Problem Summary List
IV error
Lab results or X-ray results documented/abnormal values without
follow-up
Lab/radiology issues
Wrong data reported
Failure to perform test ordered
Lost/mislabeled specimen
Wrong study ordered
Improper prep for procedure
No requesting physician/location on request form
Prolonged time delay in reporting test results, with adverse
effects
Lab/X-ray results not recorded
Laboratory/radiology support
Wrong data reported

Prolonged time in reporting results adversely affects patient care

Failure to perform diagnostic procedure
Lost specimen
Other
Medication error/reaction
Medication/treatment error, reaction, or complication
Missed diagnosis
Needle stick/parenteral blood exposure
Newborn less than 6 weeks of age not evaluated by Peds
No consent obtained for invasive procedure
No documentation of, or inadequate or incorrect, patient instruction
Psychiatry
Elopement
Hospital-incurred incident
Injury using restraints
Medication error
Staff noncompliance with hospital restraint policy
Suicide gesture/attempt while hospitalized
Unexpected drug reaction
Unplanned transfer to another acute-care hospital
Same-day Surgery
All other cancellations
Cancel/emergency arose
Cancel/patient request
Cancel/staff illness
Post-op infections
Unplanned admission for night
Social Work
Failure to recognize psychiatric disorder
Inadequate discharge plan
No discharge plan
Recurring spouse or child abuse
Urology
Admission for scrotal pain less than two weeks post-vasectomy
Hospitalization for UTI or bleeding within less than two weeks of
O/P cystoscopy
IV contrast reaction requiring hospitalization
Renal hemorrhage post-op
Scrotal hematoma post-op