Patient safety indicators need careful documentation

Alexandra Penney, RN, MPH
Clinical project manager, Oregon Region Quality Management and Medical Staff Services

April 16, 2014

Next year, patient safety indicators, or PSIs, will be added to the federal Value-Based Purchasing and Hospital Acquired Conditions programs. Under both of these CMS programs, hospitals that don’t meet certain targets will be penalized financially. Additionally, provider-specific PSI reports now are available and eventually may be added to the Physician Compare website. 

PSIs are derived strictly from ICD-9 coding and measure potential complications that result from medical care. There is no validation or review of this data before it is published, so our complication rates rest solely on documentation and subsequent coding. Therefore, clinical documentation and coding must accurately reflect the patient’s story. 

One indicator in particular – PSI 15, accidental puncture or laceration – contributes 43 percent to the total PSI 90 score. (The PSI 90 is a composite indicator made of eight different PSIs.) This indicator captures an injury to an organ or blood vessel that was unintended and not caused by an underlying disease process. A slip of the scissors that accidentally cuts bowel tissue, for example, would be labeled a PSI 15. The rationale is that these types of injuries result in adverse events for patients, increase health care costs and are largely preventable. 

If the documentation is unclear the codes may be misapplied, resulting in an inflated PSI rate for the hospital and the surgeon or proceduralist. 

How do we improve the PSI measures?
The first step is to ensure that our documentation and coding practices accurately capture true complications. This accuracy allows us to better understand surgical and procedural safety opportunities. 

Here in Oregon, a year-over-year chart review of 226 cases involving accidental punctures or lacerations found that nearly 40 percent of the records were missing the “Complications” line. This kind of omission can result in inaccurate coding.


All Oregon professional staff who perform procedures must:

  1. Include a completed “Complications” line in every operative or procedure report, whether complications are present or not. The clearer the documentation, the better. 
  2. Add details and context to every operative report. Was the laceration or puncture unavoidable or necessary due to patient complexity? Was it accidental? 
  3. Avoid ambiguous language such as, “In the setting of…” or “Needle was placed instead in...” Self-reporting is uncomfortable, but it is better that the surgeon or proceduralist drive the complications decision than leave the documentation open to misinterpretation.

Improved documentation in addition to the support of our region’s clinical documentation specialists and coders will help us improve our PSI 15 rate. Only then can we use the PSI rates for what they were intended: to improve patient safety.