SI

Indicator Definition Formula Remarks

No
Adverse event: Any untoward
“A medication error is any medical occurrence that may
preventable event that may cause present during treatment with a
or lead to inappropriate pharmaceutical product but
medication use or harm to a which does not necessarily
patient.”(FDA Definition) have a causal relationship with
this treatment.
"A medication error is any
preventable event that may cause Total number of medication errors in a Adverse drug reaction: A
or lead to inappropriate month response to a drug which is
X 100
medication use or patient harm Total number of discharges and deaths noxious and unintended and
while the medication is in the in that month which occurs at doses
control of the health care normally used in man for
professional, patient, or prophylaxis, diagnosis, or
Percentage of consumer. Such events may be therapy of disease or for the
1 medication errors. related to professional practice, modification of physiologic
health care products, procedures, function.
and systems, including
prescribing; order Therefore ADR = adverse
communication; product event with a causal link to a
labeling, packaging, and drug
nomenclature; compounding;
dispensing; distribution; Adverse drug event: The FDA
administration; education; recognizes the term adverse
monitoring; and use."-{ The drug event to be a synonym for
National Coordinating Council adverse event.
for Medication Error Reporting
and Prevention (NCC MERP)} In the patient safety literature,
the terms adverse drug event
Errors with medication can arise and adverse event usually
due to a number of factors. Some denote a causal association
of the most common causes of between the drug and the

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these devastating mistakes event, but there is a wide
include the following: spectrum of definitions for
these terms, including harm
 Doctor failure to note caused by a
potential drug interactions • drug
(Adverse event) • harm caused by drug use,
and
Packaging and Labeling—
• a medication error with or
Medicine packaging and/or
without harm
labeling can cause confusion, for
different medications may look
Institute of Medicine: “an
the same.
injury resulting from medical
intervention related to a drug”,
Similar Drug Names—Look
which has been simplified to
alike and sound alike drug
“an injury resulting from the
names can cause one product to
use of a drug”
be mistaken for the other. For
Adverse drug events extend
the most current USP Use
beyond adverse drug reactions
Caution Avoid Confusion
to include harm from
Similar Drug Names, list, visit
overdoses and under-doses
www.usp.org/patientSafety/brief
usually related to medication
sArticlesReports/ qualityReview
errors.
A minority of adverse drug
Medication Orders—
events are medication errors,
Prescribers’ illegible
and medication errors rarely
handwriting can result in
result in adverse drug events.
misinterpretation and incorrect
transcription of written
medication orders.

Abbreviations—Health care
providers often use abbreviations
for drug names and/or directions
for use. While abbreviations
save time, they can be
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 misinterpreted. Using an
abbreviation for a drug name can
lead to a patient receiving the
wrong drug. Using an
abbreviation of a direction can
result in a patient taking the
medicine the wrong way.

* Incorrect / incomplete medical

evaluations
* Rushed attempts to treat as
many patients as possible
* Administration or prescription
of incorrect drug or dosage
* Administrative errors
* Lack of communication

It is mandatory that the

Total number of transfusion reactions organization should capture
in a month feedback regarding every
X 100
Blood transfusion reactions are a Total number of transfusions in that transfusion (including the ones
problem caused by receiving month without reaction) as this would
blood. The most common enable it to capture all
Percentage of problem is an allergic reaction. transfusion reactions. These
Allergic reactions may cause are then analyzed (by
2 transfusion itching, hives or a rash, and individual/ committee as
reactions rarely, may be associated with decided by the organization)
swelling, coughing, wheezing, and appropriate
and difficulty breathing ( -CDC) corrective/preventive action is
taken. The organization shall
maintain a record of
transfusion reactions.

If pre medications are given to

prevent the allergic reactions
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 during the time of transfusion,
it also needs to be captured in
the feed backs.

Allergic reactions are most

often associated with the
development of urticaria or
other rash, pruritus, wheezing,
or angioedema within several
hours of transfusion. These
reactions are temporally
limited, self-resolving, and
generally pose little risk of
causing lasting harm. Mild
reactions often consist of a
limited increase of temperature
without other symptoms or a
localized urticarial exanthem.
In moderate and severe
reactions, rigors and fever may
be severe with rapid onset and
associated with other
symptoms, and urticaria may
be extensive and painful or
include respiratory or other
systemic symptom. During the
early stages of a reaction it
may be difficult to ascertain
the cause.

Only SUTI will be captured

Symptomatic
Number of urinary catheter
Urinary tract
3 associated UTIs in a month X
infection rate
Number of urinary catheter days in 1000
(SUTI)
that month
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 VAP will be captured. The
Number of ventilator associated institution can also collect data
Ventilator pneumonias in a month X on respiratory tract infections,
4
associated Number of ventilator days in that 1000 where intensive care settings
pneumonias month don’t have ventilators
(VAP)
Central Line
Associated Blood Number of central line associated blood
X
Stream Infection stream infections in a month
1000
(CLABSI) Number of central line days in that month
5

Surgical site  For the definition of

infection rate* Number of surgical site infections numerator and
in a given month X denominator refer to
6 a) Superficial Number of surgeries performed 100 CDC Atlanta
b) Deep in that month guidelines

An event that results in a person All types of falls are to be

coming to rest inadvertently on included whether they result
the ground or floor or other from physiological reasons
lower level. (fainting) or environmental
1.Falls may be: Number of falls in a given month reasons. Assisted falls (when
Incidence of falls  at different levels - ie, another person attempts to
7 from one level to ground X 100 minimize the impact of the fall
Number of discharges and deaths in
level eg. from beds, that month by assisting the patient’s
wheelchairs or down stairs descent to the floor) should be
 on the same level as a result included.
of slipping, tripping, or (NDNQI, 2005)
stumbling, or from a
collision, pushing, or

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 shoving, by or with another
person
 below ground level, ie into a
hole or other opening in
surface
Patient Falls: Unplanned descent
to the floor with or without
injury to the patient
A pressure sore is a lesion that * Braden scale for predicting
develops on the skin and pressure ulcer risk explained
underlying tissues due to below
unrelieved pressure usually over Number of patients who develop new
Incidence of bed a bony prominence. The skin and /worsening of pressure ulcer in a given
sores after tissues rely on an adequate blood X
month
8 supply for oxygen and nutrients. 100
admission Number of discharges and deaths in that
When tissues are compressed for month
an extended period from hours to
days, blood supply can be cut
off, leading to development of a
sore.

For a bed to be included in the

Number of inpatient days in a official count, it must be set
given month up, staffed, equipped and
X 100
Number of available bed days available for patient care.
in that month Inpatient Days: A patient day
Bed occupancy is the unit of measure denoting
rate lodging provided and services
9
rendered to inpatients between
The bed occupancy rate is the the census taking hours
percentage of official beds (usually at midnight) of two
occupied by hospital inpatients successive days. A patient
for a given period of time. – formally admitted who is
(Basic statistics for health discharged or dies on the same
information management day is counted as one patient
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 technology By Carol E. Osborn) day, regardless of the number
The occupancy rate is a of hours the patient occupies a
calculation used to show the hospital bed. For patients
actual utilization of an inpatient switched from observation to
health facility for a given time inpatient status, the patient day
period. count should begin on the day
the patient was officially
admitted as an inpatient.
Includes acute care and days
from Distinct Part Units
(DPU). Excludes swing-bed,
long-term care and newborn
beds.
The number of beds used
to care for hospital admitted
patients in their place of
residence as a substitute for
hospital accommodation. Place
of residence may be
permanent or temporary
Length of stay (LOS) is a term Available bed days- It is the
used to measure the duration of a Number of inpatient days in a given product of number of inpatient
single episode of hospitalization. month beds and number of days in
Average length of Inpatient days are calculated by Number of discharges and deaths in that month.
stay (combined subtracting day of admission that month Number of inpatient days-It is
and speciality from day of discharge. However, a sum of daily inpatient
9
wise) persons entering and leaving a census.
hospital on the same day have a While calculating the overall
length of stay of one length of stay and available
number of inpatient beds,
rehabilitation and day care
beds should not be considered.
A needle stick injury is a Parenteral exposure means
Incidence of
percutaneous piercing wound Number of parenteral exposures in injury due to any sharp.
10 needle stick X 100
typically set by a needle point, a given month
injuries
but possibly also by other sharp The degree of risk is directly
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 instruments or objects. Number of inpatient days in that related to a number of factors
month including the inherent nature
of peri-operative work, routine
and concentrated use of
various types of sharp
instruments and exposure to
large amounts of blood, body
fluids and tissue. Protective
equipment, such as masks and
face shields, required for the
purpose of patient and provider
protection, can add to exposure
risk as it creates greater
difficulties in communicating.
Limited space and visibility
within operative fields, under-
staffing, emergent patient care
situations, pace of work,
distractions and ambient noise
may increase the risk of
sharps injuries and blood borne
pathogen exposures5,

Medication errors and near misses (JCI)

The organization has a process to identify and to report medication errors and near misses. The process includes defining a medication error and
near miss, using a standardized format for reporting, and educating staff on the process and importance of reporting. Definitions and processes
are developed through a collaborative process that includes all those involved in the different steps in medication management. The reporting
process is part of the organization’s quality and patient safety program. The reports are directed to one or more individuals who are accountable
for taking action (also see QPS.7). The program focuses on preventing medication errors through understanding the types of errors that occur in
the organization and in other organizations and why near misses occur. Improvements in medication processes and staff training are used to
prevent errors in the future. The pharmacy participates in such staff training. (JCI)

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 BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK

1. Completely Limited: 2. Very Limited: 3. Slightly Limited:

Sensory 4. No Impairment
Unresponsive (does not moan, flinch, or Responds only to painful stimuli Responds to verbal commands but cannot
Perception Reponds to verbal
grasp) to painful stimuli, due to diminshed Cannot communicate discomfort always communicate
command. Has no
level of consciousness or sedation, Except by moaning or restlessness, discomfort or need to be turned,
Abiltity to respond OR sensory deficit which
OR OR
meaningfully to Limited ability to feel pain over most of would limit ability to
Has a sensory impairment, which limits Has some sensory impairment, which
pressure feel or voice pain or
body the ability to feel pain or discomfort limits ability to feel pain or
related discomfort surface. discomfort
over 1/2 of body. discomfort in 1 or 2 extremities.
Moisture
1. Constantly Moist: 2. Moist: 3. Occasionally Moist: 4. Rarely Moist:
Degree to which Perspiration, urine, etc keep skin moist Skin is often but not always moist. Skin is occasionally moist, requiring Skin is usually dry;
skin is almost constantly. Dampness is detected Linen must be changed at least once a an extra linen change approximately linen requires changing
exposed to every time patient is moved or turned. shift. once a day. only at routine intervals.
moisture
4. Walks Frequently:
2. Chairfast: 3. Walks Occasionally:
Activity Walks outside the room
Ability to walk severely limited or Walks occasionally during day but
1. Bedfast at least twice a day and
nonexistent. Cannot bear own weight for very short distances, with or
Degree of physical Confined to bed. and/or must be assisted into chair or without assistance. Spends majority
inside room at least
activity once every 2 hours
wheel chair. or each shift in bed or chair.
during waking hours.
Mobility
4. No Limitations:
2. Very Limited: 3. Slightly Limited:
1. Completely Immobile: Makes major and
Ability to change Does not make even slight changes in body Makes occasional slight changes in body or Makes frequent though slight changes
frequent changes in
and extremity position but unable to make frequent in body or extremity position
or extremity position without assistance. position without
control body or significant changes independently. independently.
assistance.
position
4. Excellent:
1. Very Poor: 3. Adequate:
2. Probably Inadequate: Eats most of every
Never eats a complete meal. Rarely eats Eats over half of most meals. Eats a
Rarely eats a complete meal and generally eats meal. Never refuses a
more than 1/3 of any food offered. Eats 2 total of 4 servings of protein (meat,
only about 1/2 of any food offered. Protein meal. Usually eats a
Nutrition servings or less of protein (meat or dairy dairy products) each day.
intake includes only 3 servings of meat or total of 4 or more
products) per day. Takes fluids poorly. Occasionally will refuse a meal, but
dairy products per day. Occasionally will servings of meat and
Usual food intake Does not take a liquid dietary supplement, take a dietary supplement,
will usually take a supplement if offered,
dairy products.
pattern OR OR
OR Occasionally eats between
Is NPO and/or maintained on clear liquids Is on a tube feeding or TPN regimen,
Receives less than optimum amount of meals. Does
or which probably meets most of
liquid diet or tube feeding. not require
IV for more than 5 days. nutritional needs.
supplementation.
Friction and 1. Problem: 2. Potential Problem: 3. No Apparent Problem:
Shear Requires moderate to maximum assistance Moves feebly or requires minimum Moves in bed and in chair

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 in assistance. During a move skin independently and has sufficient muscle
moving. Complete lifting without sliding probably slides to some extent against strength to lift up completely during move.
against sheets is impossible. Frequently sheets, chair, restraints, or other devices. Maintains good
slides down in bed or chair, requiring Maintains relatively good position in chair or position in bed or chair at all times.
frequent repositioning with maximum bed most of the time but occasionally slides
assistance. Spasticity, contractures, or down.
agitation leads to almost constant friction.
TOTAL SCORE
(Addressograph)

Perform Braden Scale on admission, quarterly, after major change, after return from Hospital
When Braden Scale Score 16 or less, implement Pressure Ulcer Prevention Protocols
1) Circle type of pressure reduction device used:
State Air, Alternating Pressure, Low Air Loss Mattress, Other ____________ Date: _______ Initials: ________
2) Nutritional Consult ordered: Date: _______ Initials: ________ Date: _____ Initials: _______
3) (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk)

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