The Saudi Patient Safety

Indicators Manual
October 2024
V 1.0

1
Table of Contents
Preface 3
Acknowledgement 4
1. Introduction 7
1.1. Background of Patient Safety Measurement: 7
1.2. Patient Safety Indicators (PSIs): 7
1.3. Laying the Foundations for Enhanced Patient Safety in KSA 8
1.4. Bridging the Gaps: The Drive for Standardized Patient Safety
Indicators in KSA 9
2. Methodology
10
2.1 Current Status Assessment: 10
2.2 Governance Structure: 11
2.3. Unifying Stages: 11
2.4 Essential Patient Safety Indicators: 20
Complementary Patient Safety Indicators: 21
Recommendation: 24
3. Essential Patient Safety Indicators Cards (Operational Definition) 25
Rate of Patient Falls 25
Incidence of Hospital Acquired Pressure Injury rate 26
Incidence of Hospital Associated Venous Thromboembolism (VTE) Rate 27
Central Line-Associated Bloodstream Infection (CLABSI) Rate 28
In-Hospital Mortality Rate for Myocardial Infarction 29
Maternal Mortality Ratio 30
Infant Mortality Rate 31
Nurse Vacancy Rate 32
Percentage of Hand Hygiene Compliance 33
Percentage of Patients with at Least One Outstanding Unintentional
Medication Discrepancy (on admission) 34
References: 35
Appendix A: Complementary Patient Safety indicators Cards 36
In-Hospital Mortality Rate for Stroke 36
The 30 Days Unplanned All-cause Readmission Rate 37
Catheter-Associated Urinary Tract Infection (CAUTI) Rate 38
Surgical Site Infection (SSI) Rate 39
Percent of Patients with Medications Reconciled within 24 hours of the
decision to admit the patient 40
Percentage of High-Risk Patients Provided VTE Prophylaxis 41
Proportion of patients assessed on admission for VTE and bleeding risk 42
Transfusion-related Adverse Reactions 43
Antibiotic received within one hour prior to surgical incision 44
Critical Laboratory Test Result Communication 45
Birth trauma 46
The First-time Percentage of Caesarean Section 47
First Medical Contact-Device Time 48
Door-to-Needle (DTN) Time 49
Ventilator-Associated Event (VAE) Rate 50
Obstetric Anal Sphincter Injuries OASIS 51
Perioperative Mortality Rate (POMR) 52
Proportion of Sepsis patients who received early management bundle 53
Multi Drug Resistant Organism Rate 54
Pregnant women that have a minimum of 8 ANC visits starting before
14 weeks of pregnancy 55

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Preface:
Under the ambitious vision of Saudi Vision 2030, the nation's healthcare sector is
undergoing a transformative journey, spearheaded by the Health Sector Transformation
Program (HSTP). This transformation seeks not only to enhance the quality of healthcare
services but also to ensure the safety and wellbeing of each patient treated within our
system. In line with these objectives, the Saudi Patient Safety Center (SPSC) has been
leading efforts to elevate patient safety standards across the Kingdom.
This manual is a testament to our commitment to these goals. It is designed to standardize
Patient Safety Indicators (PSIs) across all healthcare sectors, providing a consistent,
evidence-based approach to measuring and improving patient safety. The standardization
of PSIs is crucial; it enables us to not only monitor but also benchmark our progress against
international standards, ensuring that our healthcare services can be globally competitive
and locally effective.
Through this initiative, we aim to provide our healthcare professionals with the tools they
need to identify and prioritize patient safety concerns. By aligning our safety measures
with the best global practices, we can more effectively direct our improvement efforts
where they are most needed. This manual will guide our actions and serve as a benchmark
for measuring progress. It is a key component of our vision to achieve safer healthcare
across the Kingdom, aligning with Vision 2030’s goals and demonstrating our unified
commitment to excelling in patient safety standards.

Dr. Ali Asery

Director General
Saudi Patient Safety Center

Copyrights ©
Copyright 2024 by the Saudi Patient Safety Center - All rights reserved.
This document is available on the SPSC website, www.spsc.gov.sa. This document or parts of it may be printed
for individual, not-for-profit use, or for educational purposes within your organization provided that the
contents are not subject to modifications in any manner and that proper attribution is given to SPSC and as
the source of the content. Alteration of the contents of this document or using it in any commercial context
without prior approval from the publisher is prohibited.

This version (1.0) initially targets hospital settings, the SPSC, in collaboration with national teams, will review
and update the manual and definitions every three years, or as needed, based on emerging national priorities.

3
Acknowledgement:
The Saudi Patient Safety Center (SPSC) acknowledges with gratitude the essential
contributions of advisory committee members, representatives from healthcare sectors,
taskforce teams, SPSC personnel, and scientific committee members. Their expertise and
dedication have been instrumental in the development of this key document as part of our
national initiative to standardize patient safety metrics. We value their commitment to
sharing knowledge, guiding discussions, and dedicating time to ensure the success of this
important work.

List of Contributors:
Advisory Committee:
Dr. Ali Asery Dr. Aeshah Alsagheir
Chairman Member
Saudi Patient Safety Center Ministry of Health

Mr. Abdulaziz Abdulbaqi Dr. Rana Almandil

Member Member
Ministry of Health Health Sector Transformation Program

Saudi Patient Safety Center:

Mr. Faisal Alotaibi Dr. Rakan Almogheer
Project Lead Member

Dr. Bader Alharbi Dr. Rawan Alsultan

Member Member

Dr. Mohammed Alwadei Ms. Alia Albaharnah

Member Reviewer

Mr. Ahmed Najjar

Reviewer

4
Healthcare Sectors Representatives:

Mr. Abdullah Almana Mr. Mohammed Altammimi

Member Member
Ada'a Health Program Saudi Health Council

Dr. Ahmed Alkhalifah Mr. Mohammed Assiri

Member Member
Council of Health Insurance General Directorate of Medical Services at
the Ministry of Interior

Ms. Arwa Ezzat Dr. Mufareh Alkatheri

Member Member
King Faisal Specialist Hospital & Research Ministry of National Guard Health Affairs
Center

Dr. Fahmi Al-Senani Dr. Sameeh Ghazal

Member Member
Healthcare Development Holding Public Health Authority
Company

Dr. Maha Aleid Ms. Sofia Macedo

Member Member
Saudi National Institute of Health Center for National Health Insurance

Mr. Mohammed Alhajjy Dr. Yasser Alotaibi

Member Subject Matter Expert / Member
King Saud University Medical City Ministry of Defense Health Services

Mr. Mohammed Alqarni Dr. Yousef Almutairi

Member Member
Ministry of Health Saudi Central Board for Accreditation of
Healthcare Institutions

5
Task Force Teams Members:
Dr. Abdulaziz Alshaer Mr. Majed Alshehri
Member Member
King Fahd Military Medical Complex, MODHS Prince Sultan Cardiac Center, MODHS

Mr. Abdullah Albattal Dr. Majid M Alshamrani

Member Member
Ministry of Health Ministry of National Guard Health Affairs

Dr. Abdulrahman Al Raizah Ms. Mawahib Wang

Member Member
King Abdulaziz Medical City, MNGHA Ministry of Defense Health Services

Dr. Ahmed Alayoubi Dr. Mohammed Qashqari

Member Member
Al-Yamama Hospital, Riyadh Second Health Public Health Authority
Cluster

Dr. Aiman Ramadan Mr. Mohammed Saleem

Member Member
King Abdulaziz Medical City, MNGHA King Abdullah Medical City, Makkah Health
Cluster

Dr. Alaa Alomari Mr. Nawaf Alzahrani

Member Member
Saudi Patient Safety Center Saudi Patient Safety Center

Mr. Ashraf Rababah Dr. Nayif Alsayari

Member Member
King Faisal Specialist Hospital & Research Ministry of Defense Health Services
Center

Dr. Dalia Alghamdi Dr. Roa Altaweli

Member Member
Ministry of Defense Health Services Princess Nourah bint Abdulrahman
University

Dr. Ghadeer Banasser Dr. Roaa Khinkar

Member Member
Saudi Food and Drug Authority King Abdulaziz University

Dr. Haitham Badr Dr. Sameeh Ghazal

Member Member
Ministry of Interior Medical Services Public Health Authority

6
1.Introduction
1.1. Background of Patient Safety Measurement:

In late 1999, the landmark Institute of Medicine (IOM) report ‘To Err Is Human’, revealed serious gaps in
the delivery of safe and high-quality patient care. The report highlighted that annually, 44,000 to
98,000 patients fall victim to preventable medical errors(1). This revelation spotlighted the issue of
preventable harm within the medical field, catalyzing the origin of the modern patient safety discipline.
The quantified evidence provided by this report validated the magnitude of the patient safety challenge,
emphasizing the urgent need for systemic approach for quality monitoring (1,2).
Since the publication of 'To Err Is Human', healthcare systems have acknowledged the crucial role of
measuring adverse events. Nonetheless, this endeavor remains intricate, predominantly due to the
retrospective nature of tracking such events, and the absence of a single validated tool to offer a
comprehensive view of patient safety. This complexity resembles to the tale of five blind men describing
an elephant, where varying perspectives emerge based on the methodology used for safety
measurement (3).
In order to accurately capture and measure patient safety events, a variety of approaches are utilized,
encompassing retrospective chart reviews with trigger tools, voluntary error reporting systems, and
Patient Safety Indicators (PSIs). Each of these methods offers unique advantages, yet each comes with
inherent limitations. Retrospective chart reviews provide comprehensive, in-depth clinical information,
crucial for detailed examine (4). However, this method is so labor-intensive that its routine application in
monitoring hospital safety performance is not feasible. On the other hand, voluntary error reporting
systems play a pivotal role in identifying cases for quality improvement initiatives within hospitals,
however, they are heavily shaped by the existing reporting culture within healthcare organizations (3).
In light of these limitations, Patient Safety Indicators (PSIs) aim to bridge the gaps left by traditional
methods through a more effective and holistic approach to measure patient safety.

1.2. Patient Safety Indicators (PSIs):

Performance measurement in healthcare has long been a cornerstone, serving various purposes such as
evaluating care quality, service costs, and overall population health. Industrialized nations have actively
embraced performance measurement to tackle persistent healthcare challenges (5). In response to a
proliferation of indicators, the World Health Organization (WHO) and the Organization for Economic
Cooperation and Development (OECD) have emerged as pioneers, advocating for improved health system
evaluation (5). This focus on indicators is echoed by important initiatives like OECD's 'Healthcare Quality
Indicators' and WHO's 'The World Health Report 2000 - Health Systems: Improving Performance',
emphasizing the pressing need for standardized metrics to drive healthcare improvement efforts (5).
Over the years, Patient Safety Indicators were originally integrated into broader quality performance
measurement programs, illustrating their inherent connection and multifaceted utility beyond patient
safety alone. For instance, the Joint Commission's Hospital Core Measures and the International Quality
Indicator Project (IQIP) (6).
The Patient Safety Indicators (PSIs) originated from the Agency for Healthcare Research and Quality's
Quality Indicators (QIs) initiative in 2003 to address the need for comprehensive quality metrics (7).
Comprising 20 Provider-level and 7 Area-level Indicators, PSIs continuously evolve to reflect the latest
research, clinical practices, and policy changes. These indicators focus on adverse events in hospitals,
utilizing inpatient discharge data to identify areas for patient safety improvement (7). In 2009, AHRQ
introduced the Patient Safety for Selected Indicators PSI-90 composite measure, which combines 10
PSIs to assess hospital performance nationally and regionally (8). The Centers for Medicare and Medicaid
Services (CMS) adopted PSI-90 into programs like the Hospital-Acquired Condition Reduction and
Hospital Value-Based Purchasing, where hospitals with poor PSI-90 scores face financial penalties. This
highlights PSIs' role not only in driving improvements but also in establishing accountability in healthcare
systems (4).

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 In 2015, a significant advancement was marked by the National Patient Safety Foundation (NPSF) with
the release of a pivotal report titled "Free from Harm: Accelerating Patient Safety Improvement Fifteen
Years After To Err Is Human." This report presented eight crucial recommendations to advance patient
safety. Among these was the call for the formation of a standardized set of process and outcome metrics
intended for nationwide application, highlighting the continuing efforts to elevate patient safety
protocols and measurements (3).
While AHRQ PSI has made significant strides in the U.S., on the other hand, a significant gap in global
healthcare data is the absence of uniform measures for evaluating the quality of national health
systems, as seen in resources like the OECD Health Data. This lack complicates international
benchmarking efforts and hinders improvements in patient safety and healthcare quality. To tackle this
challenge, the OECD Health Care Quality Indicators Project (HCQI) launched a global initiative, uniting 21
countries, the World Health Organization (WHO), the European Commission (EC), the World Bank, and
leading research organizations, including the International Society for Quality in Health Care (ISQua) and
the European Society for Quality in Healthcare (ESQH). Their mission is to develop and apply uniform
healthcare quality indicators across five priority areas, with Patient Safety Indicators (PSIs) at the
forefront, to facilitate global benchmarking and the pursuit of superior healthcare practices and
outcomes (9).
In Europe, the Safety Improvement for Patients in Europe (SIMPATIE) project, initiated in 2003, primarily
aimed to enhance patient safety standards regionally. Orchestrated by the Dutch Institute for Healthcare
Improvement and including pivotal partners such as the Council of Europe and the European Society for
Quality in Healthcare, the SIMPATIE project embarked on creating a common patient safety lexicon (10).
This endeavor was propelled by comprehensive literature reviews, expert group consultations, and
collaborative efforts among participating countries. The project encompassed multiple work packages,
each focusing on different aspects of patient safety, underscoring the initiative's comprehensive
approach to improving healthcare safety across the EU (10). A key goal of SIMPATIE was the
development of a unified set of Patient Safety Indicators (PSIs) to standardize safety measures within
EU healthcare facilities. Specifically, one of the pivotal work packages dedicated itself to the unification
of PSIs, highlighting the project's commitment to establishing standardized safety protocols (10).

1.3 Laying the Foundations for Enhanced Patient Safety in KSA

In alignment with Saudi Vision 2030's aspirations for a vibrant society, the Health Sector Transformation
Program (HSTP) launched in 2016 is pivotal. It is dedicated to restructuring the healthcare sector to
enhance service quality and efficiency, facilitate access to healthcare services, promote health risk
prevention, and improve traffic safety. As a significant step in fulfilling one of HSTP's initiatives, the
Saudi Patient Safety Center (SPSC) was established in 2017 setting a regional precedent. Recognized
formally by a Council of Ministers' ordinance in 2020, SPSC is charged with crafting a framework to
elevate healthcare safety standards (11).
The establishment of the SPSC was driven by the pressing need to address the challenges of patient
safety within the Kingdom's healthcare system. Despite individual efforts to improve patient safety,
these efforts remained scattered and uncoordinated. In response to patient safety challenges within the
Kingdom's healthcare landscape, the SPSC plays a multifaceted role. It has been mandated to develop a
National Patient Safety Strategy, issue safety standards and best practices, and establish a unified
platform for reporting patient safety events. Additionally, the SPSC is tasked with empowering patients
and families, collaborating internationally on patient safety, and representing Saudi interests globally.
Identifying Patient Safety Indicators, coordinating safety initiatives, organizing relevant events, and
conducting research and surveys are also among its key responsibilities. This robust mandate positions
the SPSC at the heart of the Kingdom's efforts to safeguard the well-being of patients and healthcare
providers alike (12).

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1.4. Bridging the Gaps: The Drive for Standardized Patient Safety Indicators in KSA

Knowing where things stand is the first step towards making them better, which is why we are keen on
establishing clear benchmarks for safety, as the old saying in the field states, "You can't improve what
you can't measure”. The SPSC recognizes the imperative for a holistic approach to evaluating patient
safety performance, highlighting the significance of Patient Safety Indicators (PSI) in the SPSC Mandate.
Before fulfilling the mandate and identifying PSIs, SPSC sought to assess existing patient safety
indicators which revealed a patchwork of practices. A comparative analysis between Hospitals from
different sectors highlighted a few parallels but numerous discrepancies in both the sets of indicators
used and their definitions. This is the gap the PSI project aims to fill—creating a unified set of indicators
for patient safety that will evaluate and elevate the quality of healthcare throughout the Kingdom.
Aligning with broader healthcare initiatives, this project is central to integrating patient safety into the
national measurement system. Our first objective from unifying Patient Safety Indicators (PSIs) is to set
a baseline for Saudi healthcare's safety performance for international benchmarking. The second
objective focuses on standardizing definitions of these indicators, facilitating a framework for healthcare
facilities to compare and benchmark amongst themselves within the Kingdom. Lastly, aligned with the
Health Sector Transformation Program's push for value-based healthcare, PSIs are instrumental in
measuring performance. They serve three critical purposes: promoting patient safety, ensuring
accountability in value-based care, and contributing to research that fills knowledge gaps in healthcare
(13).
Furthermore, one of the key strategic objectives in the WHO Global Action Plan for Patient Safety
2021-2030 emphasizes the importance of leveraging information to enhance patient safety and drive
improvements. Accordingly, the development of a comprehensive set of indicators is an essential action
recommended for governments to measure patient safety at a national level effectively (14). Therefore,
the SPSC commits to this global action plan by developing a set of Patient Safety Indicators,
underscoring its dedication to advancing patient safety in line with international standards.

9
2. Methodology
To ensure patient safety measures are consistent and comparable within the Kingdom's healthcare
system, a standardized approach is essential. This necessity led the SPSC project team to conduct a
systematic comprehensive review of global initiatives, including the AHRQ Patient Safety Indicators and
Europe's SIMPATIE project.
This review consisted of the stages that were followed to summarize insights and methodologies from
these leading frameworks. To ensure these indicators are customized to local healthcare needs and
aligned with global best practices. Therefore, the goal is to develop a comprehensive and cohesive set of
indicators, tailored to accurately capture and reflect the specific priorities of patient safety in Saudi
Arabia.

2.1 Current Status Assessment:

Before initiating the project, an integrative landscape assessment was conducted to understand the
existing patient safety measurement within the healthcare sector. This investigation revealed that from
over 500 KPIs analyzed across 8 different sectors, approximately 200 indicators were identified as
directly or indirectly related to patient safety. These were further condensed to around 70 unique PSIs
by merging similar indicators found across multiple sectors, thereby reducing repetition and ensuring
each unique safety concern was represented just once. However, uniformity in measurement was
lacking, with significant variations in application and interpretation across sectors. An example of this
inconsistency is the measurement of patient fall rates. Despite being tracked universally, there's a
notable divergence in inclusion and exclusion criteria, with some sectors combining falls with and
without injury into a single indicator, while others differentiate between inpatient and outpatient falls.
This discrepancy highlights the need for a standardized approach to patient safety indicators to ensure
clarity and comparability across the healthcare system.

National KPI Sources International PSI Sources

Safety Improvement for Patients in Europe

Over 500 KPIs within the national healthcare system were Over 100 PSIs endorsed by international institutions were
reviewed reviewed

Around 70 unique indicators measure patient safety in the healthcare system

Outcome Lack of an agreed-upon set of PSIs across sectors

Variations in definitions for common indicators

Figure-1: Current status assessment

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2.2 Governance Structure:
The SPSC's initiative for unifying Patient Safety Indicators (PSIs) is structured as a collaborative national
effort involving various stakeholders. The governance model for this project includes an Advisory Group
overseeing project initiation and progress. The SPSC Scientific Committee offers insights at key stages,
while Subject Matter Experts provide ongoing guidance. The Core Team, composed of representatives
from all healthcare institutions across different ecosystems, carries out the main tasks of reviewing,
analyzing, and prioritizing work, guided by the Scientific Committee's insights, SMEs' advice, and under
the Advisory Group's oversight. (Figure-2)

Advisory Committee Oversees project initiation and progress

Subject Matter Experts Provide ongoing guidance

SPSC Scientific Committee Offers insights at key stages

Core Team

Composed of representatives from

various healthcare institutions,
responsible for reviewing, analyzing, and
prioritizing the indicators

Figure-2: The governance model.

2.3. Unifying Stages:

Following the establishment of the governance structure, the SPSC meticulously developed a robust
framework to guide the selection and harmonization of Patient Safety Indicators (PSIs). This framework
was carefully designed to ensure the effective and consistent implementation of PSIs throughout the
healthcare system.

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 01 02 03 04 05

Agree on what do Review the existing Evaluate and Define the selected
Prioritize the
Patient Safety local & global shortlist the set of Patient Safety
shortlisted PSIs
Indicators mean indicators PSIs Indicators

Shared understanding Review to identify Shortlisting the PSIs Distinguish between Develop a unified
which indicators indicators meeting the based on agreed the essential and the operational definition
considered as PSIs agreed PSI definition criteria complementary PSIs for the PSIs

Figure-3: The framework to develop the National Patient Safety indicators.

Integral to the framework's design were the national patient safety priorities, identified by analyzing patient
safety events data reported to SPSC, and the international patient safety goals, both of which served as
foundational pillars.These elements, associated with the insights gained from the comprehensive current
status assessment, were pivotal in shaping the thematic areas under which the PSIs were categorized. This
strategic alignment ensures that our framework not only addresses specific local needs but also resonates
with global safety benchmarks.

Key inputs Patient Safety Areas

Maternal and Neonatal Safety

Nursing Sensitive Care

National Patient Safety Priorities Medication Safety

Mapping &
Alignment
International Patient Safety Goals Healthcare Acquired Infection

Indicators from Current Assessment Venous Thromboembolism & Bleeding Risk

Care Management

Emergency Response

Figure-4: Mapping the framework

The patient safety areas defined through this process—Maternal and Neonatal Safety, Nursing-Sensitive Care,
Medication Safety, Healthcare Acquired Infection, Venous Thromboembolism & Bleeding Risk, Emergency
Response, and Care Management—cover a broad spectrum of healthcare interactions and outcomes. By
focusing on these areas, the framework encapsulates a holistic approach to patient safety, encompassing
essential aspects of care that are critical to both local and international healthcare standards.

12
 01

Stage Agree on what do Patient Safety Indicators mean

The first stage involves the national team establishing a shared understanding
regarding the definition of PSIs. This agreement is essential before proceeding
Description with the evaluation of current practices, setting the stage for identifying which
measures will be recognized as PSIs in the evaluation phases that follow.

The definition of Patient Safety Indicators was expanded beyond the

traditional AHRQ outcome-based focus to include both process and outcome
Outcome indicators relevant to patient safety. This broader approach enables a more
comprehensive review of the KPIs.

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 02

Stage Review the existing local & global indicators

In the second stage, representatives from various healthcare sectors submitted

their Key Performance Indicators (KPIs) for analysis, aiming to discern how
patient safety measures are implemented. Subsequent detailed discussions
with these representatives helped in extracting Patient Safety Indicators (PSIs)
from the broader KPIs. Parallel consultations with regulators and partners were
Description undertaken to synchronize patient safety priorities and ensure the inclusion of
pertinent indicators. Utilizing prior assessments and prioritizations, a
comparative analysis with international PSI standards was conducted to
ascertain the comprehensiveness of the national PSIs, striving for a
comprehensive understanding of existing patient safety measures within the
healthcare system.

As a result of these collaborative efforts, the review included over 500 KPIs
and 200 PSIs actively measured across the nation, in addition to evaluating
Outcome more than 100 PSIs, that are globally recognized. This thorough examination,
followed by a process of merging similar indicators supplied by various sectors,
led to the extraction of approximately 70 unique indicators.

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 03

Stage Evaluate and shortlist the extracted Patient Safety Indicators

The third stage entailed a detailed evaluation process using eight specific
criteria, designed to guide the discerning selection of Patient Safety Indicators
(PSIs) for further prioritization. This step was critical for determining which PSIs,
identified earlier, would not proceed to the prioritization phase based on these
Description
predefined criteria. This phase of evaluation aimed to compare the previously
extracted PSIs against established criteria, with the goal of eliminating
indicators deemed less critical and shortlisting the most relevant PSIs for
further consideration.

Evaluation Criteria

1 5 Whether the indicator is included in the

Whether the indicator aligns with one of the
Saudi Health Council's Unifying framework
national patient safety priorities
for health status and system indicators

2 6
Whether the indicator aligns with one of Whether the indicator is included in the
International Patient Safety Goals Healthcare Quality Index

3 7 Whether the indicator corresponds with

Whether the indicator is relevant to high-
patient safety priorities as identified by
risk processes or populations
other involved stakeholders

4 8
Whether well-known institutions endorse Whether the indicator is being used in the
the indicator healthcare system

After applying the evaluation criteria, only 30 out of the previously reviewed
indicators fulfilled the necessary requirements and were selected for further
Outcome advancement. These indicators represent the most critical elements for
monitoring patient safety and will undergo additional prioritization in the
subsequent stage.

15
Patient Safety
Shortlisted Indicators
Area

Birth Trauma

The First-time Percentage of Caesarean Section

Maternal Infant Mortality Rate

and
Neonatal
Safety Obstetric Anal Sphincter Injuries OASIS

Maternal Mortality Ratio

Pregnant women that have a minimum of 8 ANC visits starting before 14

weeks of pregnancy

Rate of Patient Falls

Nursing Hospital Acquired Pressure Injury Rate

Sensitive
Care Nurse Vacancy Rate

Transfusion-related Adverse Reactions

Percent of Patients With at Least One Outstanding Unintentional

Medication Discrepancy (on admission)
Medication
Safety
Percent of Patients with Medications Reconciled within 24 hours of the
decision to admit the patient

16
Patient Safety
Shortlisted Indicators
Area

Catheter-Associated Urinary Tract Infection (CAUTI) Rate

Central Line-Associated Bloodstream Infection (CLABSI) Rate

Surgical Site Infection (SSI) Rate

Healthcare
Acquired Ventilator-Associated Event (VAE) Rate
Infection

Multi Drug Resistant Organism (MDRO) Rate

Percentage of Hand Hygiene Compliance

Antibiotic received within one hour prior to surgical incision

Incidence of Hospital Associated Venous thromboembolism (VTE) Rate

Venous
Thromboemb
Percentage of High-Risk Patients Provided VTE Prophylaxis
olism &
Bleeding Risk
Proportion of patients assessed on admission for VTE and bleeding risk

17
Patient Safety
Shortlisted Indicators
Area

In-Hospital Mortality Rate for Myocardial Infarction

Perioperative Mortality Rate (POMR)

Care
Management
In-Hospital Mortality Rate for Stroke

The 30 Day Unplanned All-cause Readmission Rate

Critical Laboratory Test Result Communication.

Proportion of Sepsis patients who received early management bundle

Emergency
Response
First Medical Contact-Device Time (Door-to-Balloon Time)

Door-to-Needle (DTN) Time

18
 04

Stage Prioritizing the shortlisted PSIs

In the fourth stage, the selection process involves applying a set of

performance selection criteria to the PSIs shortlisted from earlier evaluations.
Description Each member of the team has the opportunity to vote on each criterion for
every indicator, aiming to prioritize the PSIs effectively and organize them
according to their importance and applicability.

Prioritization Criteria (15)

The measure directs attention towards the ultimate change desired and strategic
Strategic
direction of the organization or healthcare system

The measure addresses a critical or serious health or health services problem (usually
Important defined as health burden or cost) such that there will be sufficient impact from collection
and service improvement initiatives

Actionable The measure addresses a service area that can benefit from improvement

Data collection, reporting, and follow-through are cost-effective (potential benefits

Feasible outweigh costs) and there is reasonable technical capacity for collection and analysis,
including risk adjustment of compared measures

Evidence- There are valid and reliable operational definitions for the measure that have been
based demonstrated through rigorous research

Relevant and The measure is relevant to most stakeholders, including policy makers, managers,
Meaningful clinicians, and the public

Using a structured voting process, the results highlighted ten indicators as

'high' priority across all criteria, underscoring the urgent need to standardize
these measures across different sectors for immediate implementation. The
Outcome remaining 20 indicators, while scored lower, were also deemed essential for
future unification efforts. The prioritization outcome was supported by the
scientific committee and endorsed by the advisory committee.

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2.4 Essential Patient Safety Indicators:

Patient Safety
Essential Patient Safety Indicators
Area

Maternal Mortality Ratio

Maternal and
Neonatal
Safety
Infant Mortality Rate

Rate of Patient Falls

Nursing
Hospital Acquired Pressure Injury Rate
Sensitive Care

Nurse Vacancy Rate

Medication Percent of Patients With at Least One Outstanding Unintentional

Safety Medication Discrepancy (on admission)

Central Line-Associated Bloodstream Infection (CLABSI) Rate

Healthcare
Acquired
Infection
Percentage of Hand Hygiene Compliance

Venous
Thromboembol
ism & Incidence of Hospital Associated Venous thromboembolism (VTE) Rate
Bleeding Risk

Care
In-Hospital Mortality Rate for Myocardial Infarction
Management

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Complementary Patient Safety Indicators:

Patient Safety
Complementary Patient Safety Indicators
Area

Birth Trauma

The First-time Percentage of Caesarean Section

Maternal and
Neonatal
Safety
Obstetric Anal Sphincter Injuries OASIS

Pregnant women that have a minimum of 8 ANC visits starting before 14

weeks of pregnancy

Nursing
Transfusion-related Adverse Reactions
Sensitive Care

Medication Percent of Patients with Medications Reconciled within 24 hours of the

Safety decision to admit the patient

Catheter-Associated Urinary Tract Infection (CAUTI) Rate

Surgical Site Infection (SSI) Rate

Healthcare
Acquired Ventilator-Associated Event (VAE) Rate
Infection

Multi Drug Resistant Organism (MDRO) Rate

Antibiotic received within one hour prior to surgical incision

21
Patient Safety
Complementary Patient Safety Indicators
Area

Venous Percentage of High-Risk Patients Provided VTE Prophylaxis

Thromboembol
ism &
Bleeding Risk Proportion of patients assessed on admission for VTE and bleeding risk

Perioperative Mortality Rate (POMR)

Care
In-Hospital Mortality Rate for Stroke
Management

The 30 Day Unplanned All-cause Readmission Rate

Critical Laboratory Test Result Communication

Proportion of Sepsis patients who received early management bundle

Emergency
Response
First Medical Contact-Device Time (Door-to-Balloon Time)

Door-to-Needle (DTN) Time

22
 05

Stage Define the selected Patient Safety Indicators

The focus shifts to defining the shortlisted PSIs that have passed previous
evaluations. This involves forming specialized taskforce teams, each with
expertise in areas like nursing and maternal care, tasked with defining assigned
indicators. They search KPI libraries and publications from renowned
Description institutions to craft the best possible definitions. Each indicator's definition
includes essential elements such as its rationale, calculation formulae with
inclusion and exclusion criteria, benchmark, comparison source, and data
collection methods.

The detailed operational definitions were developed for the 30 indicators.

Outcome These PSI cards will be presented in the next section.

23
Recommendation:
• SPSC recommends fully adopting both Essential and Complementary PSIs to cover a
comprehensive range of patient safety areas, thereby improving the overall quality of care
and ensuring thorough safety monitoring.

• SPSC emphasizes the importance of maintaining high standards in data collection and
validation to ensure the reliability and accuracy of safety metrics.

• SPSC encourages regular monitoring and reporting of PSI data to identify trends, facilitate
continuous improvement, and adjust safety strategies to achieve targets.

• SPSC encourages leadership to proactively evaluate and respond to safety performance data
to foster a proactive safety culture.

SPSC advocates for a collaborative approach involving all stakeholders in the healthcare ecosystem
to share insights, learn from each other’s experiences, and collectively enhance patient safety,
while monitoring the use of these indicators to ensure effective implementation.

24
 3.Essential Patient Safety Indicators Cards
(Operational Definition)
Name Type Code

Rate of Patient Falls Outcome SPSI.01

Definition and Rationale Calculation

Definition: Numerator: Total number of patient falls (with or without injury)

Eligible unit types include critical care, step-down, medical, surgical,
All documented falls, with or without injury, experienced by patients on medical-surgical combined and adult rehabilitation inpatient units
eligible unit types in a calendar month. Reported as Total Falls per 1,000
Patient Days. • Inclusion: All patient’s fall incidents as reported with the following
level of harm, which include but are not limited to:

Rationale: - None: resulted in no signs or symptoms of injury as determined by

post-fall evaluation (which may include x-ray or CT scan)
Patient falls occurring during hospitalization can result in serious and
even potentially life-threatening consequences for many patients. High - Minor: resulted in the application of a dressing, ice, cleaning of a
wound, limb elevation, topical medication, pain, bruise, or abrasion
performance measure rates may suggest the need to examine clinical
and organizational processes related to the identification of, and care - Moderate: resulted in suturing, application of steri-strips or skin glue,
for, patients at risk of falling, and possibly staffing effectiveness on the splinting, or muscle/joint strain
unit. - Major: resulted in surgery, casting, traction, required consultation for
neurological (basilar skull fracture, small subdural hematoma) or
internal injury (rib fracture, small liver laceration) or patients with
coagulopathy who receive blood products as a result of a fall
- Death: the patient died as a result of injuries sustained from the fall
(not from physiologic events causing the fall)

• Exclusion:

- Visitors
- Students
- Staff members
- Patients from eligible reporting unit, however, patient was not on unit
at time of fall. (e.g., an inpatient patient who falls in the radiology
department is counted as a fall for radiology, not the inpatient unit
that sent the patient to radiology)

Denominator: Patient Days

Calculation: Numerator
——————————— x1,000
Denominator

= Total Number of Falls

_____________________ x1,000
patient days

Sampling Benchmark

National Benchmark to be established through national data.

100%
NDNQI Reports

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 patient days Decrease in the rate Monthly

Reference Data Collection

All reported and validated falls, with or without injury,

AHRQ
documented in medical records and secondary risk management
Joint Commission resources (e.g., incident reports, variance reports, event reports)

25
Name Type Code

Incidence of Hospital Acquired Pressure Injury rate Outcome SPSI.02

Definition and Rationale Calculation

Definition: Number of patients who acquired (developed) a Numerator: Total Number of patients with HAPI stage 2 and
new pressure injury stage 2 or above after admission to the above in a month
hospital. It is intended to differentiate hospital-acquired
pressure injuries from those acquired in the community. For • Inclusion:
patients with pressure injuries, the origin of the pressure injury
also must be determined (hospital, hospital/unit or community - All patients with hospital acquired pressure injuries stage 2
acquired). and above reported irrespective of patient disease condition
- If a patient has more than one eligible HAPI it is counted as
Rationale: The development of hospital-acquired pressure one HAPI only
injuries (HAPI) places the patient at risk for other adverse - Include Hospital acquired pressure injuries stage 2 and above
events and increases resource consumption and healthcare related to medical devices
costs.
• Exclusion:

- Stage 1 HAPI, all Community-Acquired Pressure Injury

regardless of staging and wounds with different etiology than
pressure injuries

Denominator: Patient Days

Calculation: Numerator
————————— x1,000
Denominator

= Total Number of patients with HAPI stage 2 and above

______________________________________ x 1,000
patient days

Sampling Benchmark

National Benchmark to be established through national data.

100%
NDNQI Reports

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 patient days Decrease in the rate Monthly

Reference Data Collection

https://www.ahrq.gov/patient-safety/settings/hospital/resource/ Medical records and secondary risk management resources (e.g.

incident reports, variance reports, event reports) completed by a
pressureulcer/tool/put5.html registered nurse, and Daily Midnight census.

26
Name Type Code

Incidence of Hospital Associated Venous Thromboembolism

(VTE) Rate Outcome SPSI.03

Definition and Rationale Calculation

Definition: Numerator: Number of adult in-patient discharges (≥ 18 years old)

This measure assesses the proportion of adult patients who experience with a length of stay of 2 or more days with an additional diagnosis of
VTE, plus Number of discharges in the denominator period which
hospital-associated VTE during their hospitalization with a length of
resulted in an emergency readmission with a primary diagnosis of VTE to
stay of 2 or more days, or within 90 days following discharge per 1000 the same hospital within 90 days.
inpatient discharges.
• Inclusion:
- Adult patients who develop VTE during hospitalization with a length
Rationale: of stay of 2 or more days
This measure provides insight into the effectiveness of in-hospital VTE - Adult patients who develop VTE within 90 days of discharge
prevention program, which is essential for ensuring patient safety and • Exclusion:
outcomes. - Patients without VTE confirmed by diagnostic testing
- Patients with VTE upon presentation and no prior admission within 90
days
- Patients with VTE within 1 day of hospital stay and no prior admission
within 90 days
Denominator: Number of adult in-patient discharges (≥ 18 years old)
with a length of stay (LOS) of 2 or more days during the measurement
period.

• Inclusion:
- Patient age ≥ 18 Years
- Patient LOS ≥ 2 days
• Exclusion:
- Patients less than 18 years of age at the measurement period
- Patients with LOS < 2 days
- Maternity and pediatric hospitals are excluded
- Patients with VTE Present at Admission
Calculation: Numerator
———————————— x 1,000
Denominator

= (Number of VTE cases diagnosed during hospitalization)

+ (Number VTE diagnoses within 90 days post-discharge )
——————————————————————————————————————————————x 1,000
The number of adult in-patient discharges (≥ 18 years old)
with LOS ≥ 2 days

Sampling Benchmark

National Benchmark to be established through national data.

100%
US: < 4.2 per 1,000 in-patient discharges

Unit of Measure Improvement Noted As Reporting Frequency

Rate Per 1,000 adult in-patient discharges. Decrease in the rate Monthly

Reference Data Collection

HSE: A112
https://www.hse.ie/eng/services/publications/kpis/acute- Data can be collected from medical records, including
discharge summaries and follow-up visit reports.
hospitals-metadata-2021.pdf

27
Name Type Code

Central Line-Associated Bloodstream Infection (CLABSI) Rate Outcome SPSI.04

Definition and Rationale Calculation

Definition: Numerator: The number of CLABSI event.

Central line-associated BSI (CLABSI): A laboratory confirmed bloodstream • Inclusion:
infection (LCBI) where central line (CL) or umbilical catheter (UC) was in - All patients in covered units/periods of surveillance with CLABSI events.
place for >2 calendar days on the date of event, with day of device • Exclusion:
placement being Day 1, AND the line was also in place on the date of Patients in covered units/periods of surveillance with
event or the day before. If a CL or UC was in place for >2 calendar days - No CLABSI events
and then removed, the date of event of the LCBI must be the day of
- CLABSI events with the date of CLABSI is the day of admission/
transfer to the unit or day after.
discontinuation or the next day to be a CLABSI. - Secondary BSI from another body site
- BSI criteria (LCBI) met accompanied by one of the following:
CLABSI rate is calculated by dividing the number of CLABSI events by ‣ Extracorporeal life support (ECLS or ECMO).
the number of central line-days and multiplying the result by 1000.
‣ Ventricular Assist Device (VAD).
‣ Patient self-injects into the vascular access line.
‣ Epidermolysis bullosa.
Rationale: Denominator: Total number of central line days
Efforts to improve central line insertion and maintenance practices, with • Inclusion:
early discontinuance of lines are recommended. These efforts result in - Patients in covered units/periods of surveillance with one or more
decreased morbidity and mortality and reduced healthcare costs. Use of central line at time of daily counting in covered units/periods.
this measure to track CLABSIs through a nationalized standard for HAI • Exclusion:
monitoring, leads to improved patient outcomes and provides a Patients in covered units/periods of surveillance with:
mechanism for identifying improvements and evaluating prevention - No central line at time of daily counting
efforts.
- Devices that are not considered central lines such as:
‣ Arterial catheters unless in the pulmonary artery, aorta, or umbilical
artery
‣ Arteriovenous fistula
‣ Arteriovenous graft
‣ Atrial catheters (also known as transthoracic intra-cardiac catheters,
those catheters inserted directly into the right or left atrium via the
heart wall)
‣ Extracorporeal life support (ECMO)
‣ Hemodialysis reliable outflow (HERO) dialysis catheter
‣ Intra-aortic balloon pump (IABP) devices
‣ Peripheral IV or Midlines
‣ Ventricular Assist Device (VAD)
Calculation: : Numerator
——————————— x 1,000
Denominator
= The number of CLABSI event
———————————————————————————— x 1,000
Total number of central line days

Sampling Benchmark

No sampling applicable. All eligible patients in the unit during

NHSN reports (rate is different from unit to unit)
the defined month(s) of surveillance should be included.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 central line days Decrease in the rate Monthly

Reference Data Collection

MOH Surveillance Manual 2nd Edition 2023 Medical Records

28
Name Type Code

In-Hospital Mortality Rate for Myocardial Infarction Outcome SPSI.05

Definition and Rationale Calculation

Definition: Numerator: Number of in hospital deaths among cases meeting the

In-hospital deaths per 1,000 hospital discharges with acute myocardial inclusion and exclusion rules for the denominator
infarction (AMI) as a principal diagnosis for patients (≥ 18 years old). • Inclusion:
Excludes obstetric discharges and transfers to another hospital. - In-hospital mortality for patients ages 18 years and older, with a
principal ICD diagnosis code for AMI.
• Exclusion:
Rationale:
- Mortalities after discharge
Acute myocardial infarction (AMI) is the leading cause of death among - Death on arrival.
ischemic heart diseases. This indicator is a necessity in the context of Denominator: Total number of Discharges during the measurement
the current improvement of emergency protocols, medical addressability, period, for patients (≥ 18 years old), with a principal ICD diagnosis code
for AMI.
and modernization of hospital infrastructure.
• Inclusion:
- Patient Discharges during the measurement period, for patients (≥ 18
years old), with a principal ICD diagnosis code for AMI.
• Exclusion:
‣ Transferring to another short-term hospital
‣ Admitted from a hospice facility
‣ Patient with a principal ICD diagnosis code assigned to pregnancy,
childbirth, and puerperium
‣ Patient with a principal ICD diagnosis code assigned to newborns &
other neonates with conditions originating in perinatal period
‣ Patient with an ungroupable DRG
‣ Patients with missing information for one or more of the following:
- Discharge disposition
- Gender
- Age
- Quarter
- Year
- Principal diagnosis
Calculation: : Numerator
———————————— x 1,000
Denominator

= Number of in hospital deaths

——————————————————————————————————————— x 1,000
Total number of Discharges for AMI patients (≥ 18 years old)

Sampling Benchmark

AHRQ
100% National Benchmark to be established through national data.
US: < 51.60 per 1,000 discharges

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 discharges. Decrease in the rate Quarterly

Reference Data Collection

Data can be collected from medical records, including

AHRQ: IQI 15
discharge summaries.

29
Name Type Code

Maternal Mortality Ratio Outcome SPSI.06

Definition and Rationale Calculation

Definition: Numerator: Number of Maternal Death

Maternal Mortality Ratio (MMR) is a key indicator used to measure the Count the total number of deaths due to complications related to
number of maternal deaths that occur due to complications related to pregnancy, childbirth, or within 42 days postpartum within a specified
pregnancy, childbirth, or within 42 days postpartum per 100,000 live time frame.
births in a given time period. It reflects the risk associated with • Inclusion:
pregnancy and childbirth within a specific population - Time Frame: Maternal deaths occurring during pregnancy, childbirth, or
within 42 days postpartum.
Rationale: - Maternal Deaths: Deaths caused by complications related to pregnancy,
childbirth, orpostpartum within the specified time frame.
Reducing maternal mortality is one of the priority goals on the
international agenda. Reliable data are needed so that adequate • Exclusion:
resources can be allocated to maternal health programs for countries
(or regions in countries) that are not yet accelerating the annual
- Deaths of women unrelated or not directly caused by pregnancy,
childbirth, or postpartum complications.
reduction in maternal deaths. These data are also needed to monitor
progress toward the targets set for the new Sustainable Development Denominator: Total Number of Live Births
Goals (SDG). Calculate the total number of live births that occurred within the same
specified time frame.
• Inclusion:
- Live Births: All live births that occur within the defined period
• Exclusion:
- None
Calculation: Numerator
——————————- x 100,000
Denominator
= Number of Maternal Deaths
——————————————————————————— x 100,000
Total Number of Live Births

Sampling Benchmark

National Benchmarks: 9.42 per 100,000 births. (MOH, 2022)

International Benchmarks In OECD countries, the maternal mortality ratio
100% (MMR) averaged 10.9 deaths per 100,000 live births in 2020.
In Australia, the maternal mortality ratio (MMR) is 3 deaths per 100,000
live births.

Unit of Measure Improvement Noted As Reporting Frequency

Ratio per 100,000 live births Decrease in the rate Monthly

Reference Data Collection

World Health Organization (WHO). Maternal mortality. Geneva,

Switzerland: WHO; [Accessed January 2022]. Available from: https://
www.who.int/news-room/fact-sheets/detail/maternal-mortality
World Bank Group. World Development Indicators: Maternal Mortality Data can be collected from medical records, including discharge
Ratio. Washington, DC: World Bank Group; [Accessed January 2022]. summaries.
Available from: https://databank.worldbank.org/source/sustainable-
development-goals-global-monitoring-database

30
Name Type Code

Infant Mortality Rate Outcome SPSI.07

Definition and Rationale Calculation

Definition: Numerator: Number of Infant Deaths

Count the total number of deaths of infants under one year of age within
It is a crucial health indicator that measures the number of deaths of
a specified time frame.
infants under one year of age per 1,000 live births within a given time
• Inclusion:
period.
- Infant Deaths: Include all deaths of infants under one year of age
occurring within the specified time frame.
Rationale: • Exclusion:
The Infant Mortality Rate aids in evaluating maternal and infant health - Miscarriages and Stillbirths: Exclude miscarriages (pregnancy losses
before 24 weeks/500 gms) and stillbirths (infants born dead after 24
programs and guides policy-making to improve survival in the first year
weeks/500 gms of gestation) from both the numerator and
of life. denominator.
- Deaths Unrelated to Birth: Exclude deaths of infants caused by factors
not related to their birth or neonatal period, such as accidents,
metabolic, genetic, and congenital diseases unrelated to birth, or not
directly leading to death within the first year.
Denominator: Total Number of Live Births
Calculate the total number of live births that occurred within the same
specified time frame.
• Inclusion:
- Live Births: All live births that occur within the defined period
• Exclusion:
- None
Calculation: Numerator
——————————— x 1,000
Denominator
= Number of Infant Deaths
————————————————————————— x1,000
Total Number of Live Births

Sampling Benchmark

National Benchmarks: 7.41 deaths per 1,000 live birth (MOH,

2022)
100%
International Benchmarks In 2021, infant mortality was on
average at 4 deaths per 1,000 live births in OECD countries.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 live births Decrease in the rate Monthly

Reference Data Collection

World Health Organization (WHO). Infant Mortality. Geneva,

Switzerland: WHO; [Accessed January 2022]. Available from:
https://www.who.int/data/gho/data/themes/topics/topic-
details/GHO/infant-mortality Data should be gathered from hospital neonatal health records,
including patient records and birth registries
UNICEF. Infant Mortality. New York: UNICEF; [Accessed January
2022]. Available from: https://data.unicef.org/topic/child-
survival/infant-mortality/

31
Name Type Code

Nurse Vacancy Rate Structure SPSI.08

Definition and Rationale Calculation

Definition: Numerator: Number of vacant permanent nurse FTEs.

The vacant permanent nurse Full-Time Equivalent (FTE) The total vacant nurse Full-Time Equivalent (FTE) positions. It is
calculated by subtracting the current number of occupied nurse
indicator is defined as the measurement of the percentage of
FTE positions from the total planned nurse FTE positions in the
vacant permanent nurse FTE positions out of the total planned Nursing Department.
budgeted nurse workforce FTEs.
• Inclusion:

Rationale: - All vacant nurse positions within the Nursing Department

Ensures identification of potential critical staffing levels. • Exclusion:
-Occupied nurse FTE positions during the measurement period
within the Nursing Department.
Denominator: Number of planned budgeted nurse workforce
FTEs
• Inclusion:
- All nurses within the Nursing Department (all Job Titles)
• Exclusion:
- Any nurses working in any other department outside the
Nursing Department.

Calculation: Numerator
——————————- x 100
Denominator

Number of vacant permanent nurse FTE positions

= ———————————————————————————————————————-— x 100
Number of planned budgeted Nurse Workforce FTEs

Sampling Benchmark

UK NHS
100% • ≤ 5% Nurse Vacancy Rate: Exceeds Target
• 5.1-15% Nurse Vacancy Rate: Meets Target

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

Data can be collected from the organization’s approved Annual

2023 NSI National Health Care Retention & RN Staffing Report
Nursing Staffing Plan.

32
Name Type Code

Percentage of Hand Hygiene Compliance Process SPSI.09

Definition and Rationale Calculation

Definition: Numerator: The total number of compliant hand hygiene

Percentage of compliance to WHO standardized Hand Hygiene opportunities
(HH) method. • Inclusion:
- All observed hand hygiene opportunities in covered units/
Rationale: periods that were compliant with WHO standard hand
Hand hygiene is the most important single preventive practice in hygiene guidelines.
infection control. It is very cost-effective measure to prevent • Exclusion:
almost all types of infection. Assessing the hand hygiene rates -All observed hand hygiene opportunities in covered units/
in different units/professional categories are critical for periods that were not compliant with WHO standard hand
identifying high risk units/professional categories and planning hygiene guidelines.
potential improvement projects (including educational
campaigns and auditing) Denominator: The total number of HH opportunities observed.

• Inclusion:
- All observed hand hygiene opportunities (before touching a
patient, after touching a patient, after touching patient
surroundings, after body fluids exposure/risk, before clean/
aseptic procedure) among healthcare workers (physician,
nurses, and other healthcare workers) in covered units/
periods.

• Exclusion:
- None

Calculation: Numerator
——————————- x 100
Denominator

The total number of compliant hand hygiene opportunities

= ————————————————————————————————————————————-— x 100
The total number of HH opportunities observed

Sampling Benchmark

Convenience sampling of healthcare workers in the units,

WHO and JCI target
making sure to cover all professional categories

Unit of Measure Improvement Noted As Reporting Frequency

Percentage of hand hygiene compliance Increase in the percentage Monthly

Reference Data Collection

WHO, hand hygiene. Monitoring tools Observation

33
Name Type Code

Percentage of Patients with at Least One Outstanding

Unintentional Medication Discrepancy (on admission). Outcome SPSI.10

Definition and Rationale Calculation

Definition: Numerator: Total number of eligible patients with at least one

Unintentional Discrepancies are discrepancies in which the unintentional outstanding medication discrepancies discovered at
admission
prescriber unintentionally changed, added, or omitted
medication that the patient was taking prior to admission or • Inclusion:
during hospitalization.
- Eligible patients discovered at least one outstanding unintentional
Outstanding Discrepancies are discrepancies which are discrepancy.
identified by independent observer. • Exclusion:

Eligible Patient: All patients admitted to in-patient care unit

-Patient with intentional documented discrepancies
-Patients with intentional undocumented discrepancies
during the measured period who stayed ≥24 hours since -Patients with no discrepancies
admission date and time and received official reconciliation
within 24 hours of admission.
Denominator: Total number of eligible patients.
The purpose of this indicator is to measure the percent of
eligible patients with unintentional outstanding medication • Inclusion:
discrepancies. - All patients admitted to in-patient care unit during the measured
period who stayed ≥24 hours since admission date and time and
Rationale: This is a measure of non-intentional discrepancies received official reconciliation within 24 hours of admission
that include errors of omission, commission. If unresolved, this
• Exclusion:
category of discrepancies can lead to actual adverse drug
events. - All eligible patients with no official reconciliation done within 24 hours
of admission as applicable by data collection time

Calculation: Numerator
——————————- x 100
Denominator

Total number of eligible patients with at least one unintentional

outstanding medication discrepancies discovered
= —————————————————————————————————————— x 100
Total number of eligible patients

Sampling Benchmark

Proportional stratified random sampling by unit:

Population Sample size
≤10 % Canadian patient safety institute, the WHO High 5s
6-77 Include all population
project medication reconciliation.
78-390 78 admissions
>390 20% of all admissions

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

Medication Reconciliation form.

• Canadian patient safety institute Patient /family interview.
• The high 5s project medication reconciliation WHO Previous/current patient health records.
List of admitted patient during the measurement period by specialty.

34
 References:
1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC:
Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press;
1999. Washington, DC: National Academy Press. 1999. 700 p.

2. Downey JR, Hernandez-Boussard T, Banka G, Morton JM. Is patient safety improving? National
trends in patient safety indicators: 1998-2007. Health Serv Res. 2012;47(1 PART 2).

3. Patient Safety Network. PSNet. 2019. Measurement of Patient Safety.

4. Wachter R. Understanding Patient Safety, Second Edition. McGraw-Hill Professional Publishing,

New York. 2012;

5. Arah OA, Westert GP, Hurst J, Klazinga NS. A conceptual framework for the OECD Health Care
Quality Indicators Project. International Journal for Quality in Health Care. 2006;18(SUPPL. 1).

6. Tsang C, Aylin P, Palmer W. Patient Safety Indicators: A Systematic Review of the Literature.
London, UK: Imperial College. 2008 Oct;

7. AHRQ Quality Indicators Guide to Patient Safety Indicators [Internet]. 2003. Available from:
www.ahrq.gov

8. AHRQ. Toolkit for Using the AHRQ Quality Indicators. Preventing Pressure Ulcers in Hospitals.
2015;(Cvc).

9. Millar J, Mattke S. Selecting Indicators for Patient Safety at the Health Systems Level in OECD
Countries [Internet]. 2004. Available from: www.oecd.org/els/health/technicalpapers.

10. Mainz J. A Patient Safety Vocabulary. Network. 2007;(March).

11. Saudi Patient Safety Center [Internet]. SPSC At a Glance. Available from: https://
www.spsc.gov.sa/English/Pages/SPSC-At-A-Glance.aspx

12. Bureau Of Experts at the Council of Ministers. Ordinance of the Saudi Patient Safety Center
mandate. 2020.

13. ’Clarke J, ’Davidge M, ’James L. The How-to guide for Measurement for Improvement.

14. World Health Organization. Global patient safety action plan 2021–2030: Towards eliminating
avoidable harm e health care. World Health Organization. 2021.

15. Adair C, Simpson E, Casebeer A, Birdsell J, Hayden K, Lewis S. Performance Measurement in

Healthcare: Part II - State of the Science Findings by Stage of the Performance Measurement
Process. Healthc Policy. 2006;2(1).

35
Appendix A: Complementary Patient Safety indicators Cards

Name Type Code

In-Hospital Mortality Rate for Stroke Outcome SPSI.11

Definition and Rationale Calculation

Definition: Numerator: Number of in-hospital deaths among discharges meeting

the inclusion and exclusion rules for the denominator with subgroup
In-hospital deaths per 1,000 hospital discharges with a principal
analysis by type of stroke.
diagnosis of acute stroke for patients (≥ 18 years old).
• Inclusion: In-hospital mortality for patients aged 18 years and older,
Includes metrics for discharges grouped by type of stroke.
with a principal diagnosis of acute stroke
Excludes transfers to another hospital, discharges admitted from
• Exclusion:
a hospice facility, and obstetric discharges.
- Mortalities after discharge
- Death on arrival
Rationale:
Denominator: Total number of Discharges, for patients (≥ 18 years old),
Stroke is the leading cause of serious, long-term disability. and with a principal ICD diagnosis code for stroke with subgroup analysis
Nearly three-quarters of all strokes occur in people over the age by type of stroke (intracerebral hemorrhage, subarachnoid hemorrhage, or
of 65. The risk of having a stroke more than doubles each ischemic Stroke).
decade after the age of 55. • Inclusion:
- Patient Discharges during the measurement period, for patients (≥ 18
years old), with principal diagnosis of stroke.
• Exclusion:
‣ Transferring to another short-term hospital.
‣ Admitted from a hospice facility.
‣ Patient with a principal ICD diagnosis code assigned to pregnancy,
childbirth, and puerperium.
‣ Patient with a principal ICD diagnosis code assigned to newborns and
other neonates with conditions originating in perinatal period.
‣ Patient with an ungroupable DRG.
‣ Patients with missing information for one or more of the following:
- Discharge disposition
- Gender
- Age
- Quarter
- Year
- Principal diagnosis
Calculation: Numerator
————-———————— x1,000
Denominator

Number of in hospital deaths

= ——————————————————————————————————————————— x 1,000
Total number of Discharges for Stroke patients (≥ 18 years old)

Sampling Benchmark

AHRQ
100% National Benchmark to be established through national data.
US: < 40.12 per 1000 discharges

Unit of Measure Improvement Noted As Reporting Frequency

Rate Per 1,000 Discharges Decrease in the rate Quarterly

Reference Data Collection

AHRQ-IQI-17
Data can be collected from medical records, including
NQF:0467
discharge summaries.
https://p4qm.org/measures/0467

36
Name Type Code

The 30 Days Unplanned All-cause Readmission Rate Outcome SPSI.12

Definition and Rationale Calculation

Definition: Numerator: Number of discharged patients readmitted to the

The proportion of occurrences of a non-elective (unplanned) hospital within 30 days of discharge.
admission to hospital for any cause within 30 days of a patient Count the number of cases within the denominator with a
subsequent unplanned readmission to the same hospital less
being discharged from the hospital stay. than or equal to 30 days from discharge.
• Inclusion:
Rationale:
This indicator is essential for confirming that patients are
- Unplanned readmission
- Admission day of a subsequent discharge is less than or equal
discharged from the hospital in a condition that allows them to to 30 days of initial discharge date from an acute hospital
continue their recovery without complications, thus minimizing including patients that discharge from day surgery
the risk of adverse events that would require them to be • Exclusion:
readmitted. It helps healthcare systems focus on improving - Transfer from another acute hospital
communication, care coordination, and patient education, - Planned Readmission
thereby safeguarding patient well-being and optimizing overall
health outcomes. Denominator:The number of discharges
• Inclusion:
- All
• Exclusion:
- Death
- Stillbirth
Calculation: Numerator
————-——————— x 100
Denominator
Total Number of discharged patients readmitted
to the hospital within 30 days of discharges
= ——————————————————————————————————— x 100
The number of discharges

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

Canadian Institute for Health Information. All-Cause

Readmission to Acute Care and Return to the Emergency Medical Record
Department. Ottawa, ON: CIHI; 2012.

37
Name Type Code

Catheter-Associated Urinary Tract Infection (CAUTI) Rate Outcome SPSI.13

Definition and Rationale Calculation

Definition: Numerator: The number of CAUTI events.

CAUTI is defined as a symptomatic urinary tract infection (SUTI) • Inclusion:
or asymptomatic bacteremic UTI (ABUTI) in a patient who had an - All patients in covered units/periods of surveillance with CAUTI events
indwelling urinary catheter that was in place for >2 days and in • Exclusion:
place at the date of event or the day before. - All patients in covered units/periods of surveillance without CAUTI
events
CAUTI rate is calculated by dividing the number of CAUTIs by the - Patients in covered units/periods of surveillance with CAUTI event with
number of urinary catheter-days and multiplying the result by the date of CAUTI is the day of admission/transfer to the unit or day
1000. after
- Positive urine culture with more than two species of organisms.
Rationale: - Positive urine culture with candida species, yeast, mold, dimorphic,
CAUTI can cause excess morbidity, mortality, and length of stay fungi, or parasite.
to affected patients. Additionally, the healthcare costs Denominator:Total number of urinary catheter days
associated with treating CAUTI are increasing. Assessing the
• Inclusion:
CAUTI rates in different units are critical for identifying high risk
units and planning potential improvement projects. - All patients with indwelling urinary catheter at time of daily counting
in covered units/periods of surveillance

• Exclusion:
- Patients without indwelling urinary catheter at time of daily counting
in covered units/periods of surveillance
- Patients with urinary catheters that are not considered indwelling
urinary catheters (according to NHSN definitions) at time of daily
counting in covered units/periods. Non-recognized catheters include
suprapubic catheters, condom catheters, "in and out" catheters, and
nephrostomy tubes

Calculation: Numerator
————-——————— x 1,000
Denominator

The number of CAUTI events

= —————————————————————————————— x 1,000
Total number of urinary catheter days

Sampling Benchmark

No sampling applicable. All eligible patients in the unit during

NHSN reports (rate is different from unit to unit)
the defined month(s) of surveillance should be included.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 urinary catheter days Decrease in the rate Monthly

Reference Data Collection

MOH Surveillance Manual 2nd Edition 2023. Medical Record

38
Name Type Code

Surgical Site Infection (SSI) Rate Outcome SPSI.14

Definition and Rationale Calculation

Definition: Numerator: The number of SSI events

Infection occurs within 30 or 90 after an operative procedure • Inclusion:
that involves the skin or subcutaneous tissue (superficial
incisional SSI), deep soft tissue (deep incisional SSI), or any other
- All patients with covered procedures/periods of surveillance
with SSI events
part of the body that is opened or manipulated during the
operative procedure (organ/space SSI). • Exclusion:
SSI rate is calculated by dividing the number of SSIs by the - All patients with covered procedures/periods of surveillance
number of specific operative procedures and multiplying the without SSIs events
results by 100.
Denominator:Total number of procedures performed.
Rationale: • Inclusion:
SSI can cause excess morbidity, mortality, and length of stay to - All patients with one of the procedures included in NHSN
affected patients. Additionally, healthcare costs associated with operative procedure category(s) that are monitored during a
treating SSI are increasing. Assessing the SSI rates associated specific period of surveillance.
with different types of surgical procedures are critical for • Exclusion:
identifying high risk surgical procedures and planning potential
All patients with covered procedures/periods of surveillance
improvement projects.
with:
- Death in operative room.
- Procedure not included in NHSN operative procedure
category(s)

Calculation: Numerator
————-——————— x 100
Denominator

The number of SSIs

= ———————————————————————————————— x 100
Total number of procedures performed

Sampling Benchmark

100% NHSN reports (rate is different from surgery and surgery)

Unit of Measure Improvement Noted As Reporting Frequency

Rate Per 100 operative procedures. Decrease in the rate Monthly

Reference Data Collection

MOH Surveillance Manual 2nd Edition 2023 Medical Record

39
Name Type Code

Percent of Patients with Medications Reconciled within 24

hours of the decision to admit the patient Process SPSI.15

Definition and Rationale Calculation

Definition: Numerator: Number of patients admitted to in-patient care unit whose

medications have been reconciled.
Medication Reconciliation is a process of identifying the best
(All current medications documented or documentation of no recurrent
possible medication history (BPMH) a patient is taking currently
medication in the medication reconciliation form) within 24 hours of
or within the last two weeks and using this list to provide admissions
correct medications to the patient anywhere in the hospital.
• Inclusion:
The purpose of this indicator is to measure the percentage of - Patients whose medications have been reconciled within 24 hours of
compliance to medication reconciliation for patients within 24 admission for patients who were admitted during the measurement
hours of admissions. period.
• Exclusion:

Rationale: - Patients with no medication reconciliation done appropriately within

24 hours of admission for patients who were admitted during the
Adverse Drug Events (ADEs) are a significant cause of injury and measurement period.
death within healthcare systems. Many of these events occur Denominator: Total number of patients admitted to inpatient
due to inadequate communication among healthcare • Inclusion:
professionals and between healthcare professionals and - All admitted patients to inpatient units within the measurement period
patients during care transitions, such as hospital admissions, with their length of stay ≥ 24 hours including boarded patients in ED.
transfers between wards, and discharges. The reconciling • Exclusion:
process is an effective strategy to reduce medication ‣ Outpatients.
discrepancies and (ADEs) as patients move through interfaces of - Inpatient with length of stay less than 24 hours.
care. - All patients admitted out of the date of measurement period.
- Transferred patients from another inpatient unit within the hospital
(Patient will be counted for the transferring unit if the date of
admission to the transferring unit was within the measurement period
and his stay in this unit ≥24 hours otherwise counted to the receiving
unit).

Calculation: Numerator
———————————— x100
Denominator

Total number of patients admitted to inpatient care unit

whose medications have been reconciled
= —————————————————————————————————————————— x 100
Total number of patients admitted to inpatient

Sampling Benchmark

Proportional stratified random sampling by unit

Population Sample size
100% Canadian patient safety institute, the WHO High 5s project
6-77 Include all population
medication reconciliation.
78-390 78 admissions
>390 20% of all admissions

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Monthly

Reference Data Collection

• Medication Reconciliation forms.

• Canadian patient safety institute • Patient / Family interviews.
• Previous/Current Patient health records.
• The High 5s project medication reconciliation WHO • List of admitted patient during the measurement period by specialty.
• Inspection of current patient containers.

40
Name Type Code

Percentage of High-Risk Patients Provided VTE Prophylaxis Process SPSI.16

Definition and Rationale Calculation

Definition: Numerator: Number of patients at increased risk of VTE who

This indicator measures the percentage of high-risk patients are offered thromboprophylaxis in accordance with
international guidance
who receive appropriate thromboprophylaxis in line with
international guidelines to mitigate the risk of VTE. • Inclusion:
- All
Rationale: • Exclusion:
Thromboprophylaxis adherence for high-risk patients is critical - None
for preventing VTE-associated complications. This measure
Denominator: Number of patients assessed to be at increased
offers insights into the adherence to international guidance and
risk of VTE.
the effectiveness of VTE prevention strategies.
• Inclusion:
- All
-
• Exclusion:

- Patient age <18 year

- Patient meeting any contraindication for pharmacological or
mechanical prophylaxis
- Patient low risk for VTE

Calculation: Numerator
————-——————— x 100
Denominator

Number of patients who are offered Thromboprophylaxis

= ————————————————————————————————————————————— x 100
Number of patients assessed to be at increased risk of VTE

Sampling Benchmark

100% 100%

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Quarterly

Reference Data Collection

Tung EC, Yu SY, Shah K, Kinkade A, Tejani AM. Reassessment of

Venous Thromboembolism and Bleeding Risk in Medical Patients
Receiving VTE Prophylaxis. J Eval Clin Pract. 2020 Medical Records
Feb;26(1):18-25. doi:
10.1111/jep.13213. Epub 2019 Jul 7. PMID: 31282101.

41
Name Type Code

Proportion of patients assessed on admission for VTE and

Process SPSI.17
bleeding risk

Definition and Rationale Calculation

Definition: Numerator: Number of adult patients (≥ 18 years old) assessed

This indicator is to quantify the numbers and proportion of adult on admission for VTE and bleeding risk.
hospital admissions (≥ 18 years old) who are being risk assessed • Inclusion:
for Venous Thromboembolism (VTE) and bleeding risk. - All
• Exclusion:
Rationale:
- None
VTE and bleeding risk assessments using validated models for
Denominator: All admitted adult patient (≥ 18 years old).
all adult patients (≥ 18 years old) upon admission are central to
patient safety. They guide the provision of appropriate • Inclusion:
prophylaxis according to international guidelines, aiming to - All
reduce the incidence of preventable VTE and minimize bleeding • Exclusion:
risks. - Patient age < 18 years old
- Outpatients.
- Emergency Department visitor
Calculation: Numerator
————-——————— x 100
Denominator

Number of adult patients assessed on admission

= ————————————————————————————————————————— x 100
The number of admitted adult patients

Sampling Benchmark

100% 100%

Unit of Measure Improvement Noted As Reporting Frequency

Quarterly
Percentage Increase in the percentage

Reference Data Collection

Tung EC, Yu SY, Shah K, Kinkade A, Tejani AM. Reassessment of

Venous Thromboembolism and Bleeding Risk in Medical Patients Data can be extracted from VTE and bleeding risk assessment
Receiving VTE Prophylaxis. J Eval Clin Pract. 2020 documentation, whether from dedicated forms, medical
Feb;26(1):18-25. doi: records, or relevant patient admission files.
10.1111/jep.13213. Epub 2019 Jul 7. PMID: 31282101.

42
Name Type Code

Transfusion-related Adverse Reactions Outcome SPSI.18

Definition and Rationale Calculation

Definition: Numerator: Total number of reactions that required any

To monitor the percentage of transfusion reaction. Defined as diagnostic or therapeutic intervention.
any serious complication that occurred after a blood transfusion. • Inclusion:
All transfusion-related Adverse Reactions defined as reaction
Rationale: related to transfusion of blood which include any of these:
Transfusion-associated circulatory overload (TACO).
Monitoring transfusion-related adverse reactions is crucial for
- Transfusion-related acute lung injury (TRALI).
understanding the effectiveness of current transfusion safety - Transfusion-associated dyspnea (TAD).
measures. - Allergic reaction (where severity is severe, life threatening, or
death).
- Hypotensive transfusion reaction.
- Febrile non-hemolytic transfusion reaction (FNHTR).
- Acute hemolytic transfusion reaction (AHTR).
- Delayed hemolytic transfusion reaction (DHTR).
- Delayed serologic transfusion reaction (DSTR).
- Transfusion-associated graft vs. host disease (TAGVHD).
- Post-transfusion purpura (PTP).
• Exclusion:
- None
Denominator: The total number of transfusion of units (including
red blood cells, PLTs, plasma, and cryoprecipitate) transfused.
• Inclusion:
- All patients
• Exclusion:
- None
Calculation: Numerator
————-——————— x 100,000
Denominator
Number of Transfusion-related adverse reactions
= ———————————————————————————————————— x 100,000
The total number of units transfused

Sampling Benchmark

Benchmark to be established through national data.

Data from the National Healthcare Safety Network Hemovigilance
100% Module - United States
< 282 reactions per 100,000 transfusions in 2017

Unit of Measure Improvement Noted As Reporting Frequency

Rate of adverse reactions per 100,000 blood components transfused Decrease in the rate Annually

Reference Data Collection

Kracalik, Ian et al. “Transfusion-related adverse reactions: Data from the

National Healthcare Safety Network Hemovigilance Module - United
States, 2013-2018.” Transfusion, vol. 61,5 (2021): 1424-1434.
doi:10.1111/trf.16362
Savinkina, Alexandra A et al. “Transfusion-associated adverse events Data can be collected from medical records.
and implementation of blood safety measures - findings from the 2017
National Blood Collection and Utilization Survey.” Transfusion, vol. 60
Suppl 2, (2020): S10-S16. doi:10.1111/trf.15654

43
Name Type Code

Antibiotic received within one hour prior to surgical incision Process SPSI.19

Definition and Rationale Calculation

Definition: Numerator: Number of surgical patients with prophylactic antibiotics

To measure the percentage of surgical patients who receive initiated within one hour prior to surgical incision.

prophylactic antibiotics within one hour prior to surgical incision. • Inclusion:

- All adult surgical patients (≥ 18 years old) with prophylactic antibiotics
Rationale: initiated within one hour prior to surgical incision (or within two hours
if the patient is receiving vancomycin or fluoroquinolones).
SSI can cause excess morbidity, mortality, and length of stay to
• Exclusion:
affected patients. Additionally, healthcare costs associated with
treating SSI are increasing. Patients who receive prophylactic
- All surgical patients with prophylactic antibiotics initiated more than
one hour before surgical incision (or more than two hours if the patient
antibiotics within one to two hours before the initial incision is receiving vancomycin or fluoroquinolones).
have lower rates of SSI than patients who receive antibiotics
Denominator: All selected surgical patients with no evidence of prior
sooner or later than this window. Assessing the compliance with infection who received prophylactic antibiotics.
timely administered prophylactic antibiotics in different types of
surgical procedures are critical for identifying high risk surgical • Inclusion:
procedures and planning potential improvement projects - All adult surgical patients (≥ 18 years old) with no evidence of prior
infection who received prophylactic antibiotics.
• Exclusion:
- Patients less than 18 years of age.
- Patients who had a principal diagnosis suggestive of preoperative
infectious diseases.
- Patients with documented infection prior to surgical procedure of
interest.

Calculation: Numerator
———————————— x100
Denominator

Number of adult surgical patients with prophylactic antibiotics

initiated within one hour prior to surgical incision
= ———————————————————————————————————————————— x 100
All adult surgical patients with no evidence of prior infection
who received prophylactic antibiotics

Sampling Benchmark

Systematic random sampling of eligible patients who underwent

the target surgical category during the defined month(s) of
surveillance should be included. No sampling applicable when 100%
the number of surgical patients is small (<30 patients).

Unit of Measure Improvement Noted As Reporting Frequency

Percentage of compliance with timely administered prophylactic

Increase in the percentage Monthly
antibiotics

Reference Data Collection

CMS Medical Records

44
Name Type Code

Critical Laboratory Test Result Communication Process SPSI.20

Definition and Rationale Calculation

Definition: Numerator: Number of critical laboratory test results

Measures the effectiveness and timeliness of communicating communicated within the standard time frame (30 min) and read
back by healthcare provider, from the time of result verification.
critical laboratory test results within a standard time frame and
read back by healthcare provider from the time of result • Inclusion:
verification. - All critical laboratory test results reported
• Exclusion:
Rationale: - Non-critical test results and other non-laboratory critical test
results.
Ensures prompt response to life-threatening or significantly life-
altering conditions, enhancing patient safety and care quality.
- Previously informed known critical results
Denominator: Total number of critical laboratory test results
reported and documented in the same period.

Denominator Basis:
Count of all critical laboratory test results.

Calculation: Numerator
————-——————— x 100
Denominator

All critical laboratory test results reported within 30 min and read
back by healthcare provider from the time of result verification
= —————————————————————————————————————————————— x 100
Total number of critical laboratory test results reported in the same
period

Sampling Benchmark

100% 100%

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Monthly

Reference Data Collection

College of American Pathologists (CAP): CAP Guidelines Laboratory information system (LIS) reports and logs.
Clinical Laboratory Improvement Amendments (CLIA): CLIA Automated data extraction from LIS, supplemented by
Regulations manual verification and random audits.

45
Name Type Code

Birth trauma Outcome SPSI.21

Definition and Rationale Calculation

Definition: Numerator: Number of Birth Trauma Cases

Birth trauma refers to physical injuries sustained by a newborn Count the total number of newborns who experienced physical
during the process of childbirth. These injuries can include injuries (such as fractures, bruises, nerve injuries, etc.) during the
fractures, bruises, nerve injuries, and other trauma caused by process of childbirth within a specified time frame.
mechanical forces during delivery. • Inclusion:
- Physical Injuries Related to Childbirth: Include injuries directly
Rationale: resulting from the mechanical forces and stresses experienced
Birth trauma is a critical indicator as it directly measures the during the birthing process.
safety and quality of neonatal care during delivery. Tracking - Diagnosed Cases: Include only those cases that are clinically
birth trauma rates is essential to identify potential diagnosed or confirmed by healthcare professionals as birth-
improvements in obstetric practices, reduce preventable injuries, related trauma.
and enhance maternal and newborn care outcomes. • Exclusion:
- Exclude pre-existing congenital conditions or injuries present
before childbirth.
- Exclude injuries or traumas not specifically related to the
process of childbirth.
Denominator: Total Number of Live Births
Calculate the total number of live births that occurred within the
same specified time frame.
• Inclusion:
- Live Births: All live births that occur within the defined period
• Exclusion:
- None
Calculation: Numerator
————-——————— x 100
Denominator
Number of Birth Trauma Cases
= ———————————————————————————— x 100
Total Number of Live Births

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

American College of Obstetricians and Gynecologists (ACOG). Neonatal

Encephalopathy and Neurologic Outcome. Committee Opinion No. 656.
Washington, DC: ACOG; 2016.
Data should be collected from neonatal health records and
Towner D, Castro M, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery reports.
delivery in nulliparous women on neonatal intracranial injury. New
England Journal of Medicine. 1999; 341(23):1709-1714.

46
Name Type Code

The First-time Percentage of Cesarean Section Process SPSI.22

Definition and Rationale Calculation

Definition: Numerator: Number of Cesarean Sections for the first time on

It specifically focuses on cesarean sections performed for the pregnant women among the total the total number of cesarean
first time on pregnant women, and indicates the percentage of section deliveries within a specified time frame.
cesarean deliveries among this specific group of women. • Inclusion:
- Primary Cesarean Deliveries: Include only primary cesarean
Rationale: deliveries among pregnant women.
Measuring the rate of first-time cesarean sections is crucial for • Exclusion:
patient safety, identify patterns in obstetric care and highlight
the potential risks associated with avoidable surgical
- Recurring Cesarean Sections: Exclude repeated or secondary
cesarean deliveries in women who had undergone a previous
interventions. By focusing first-time procedures, this indicator cesarean section.
assists in targeting efforts to mitigate unnecessary risks, thus Denominator:Total number of cesarean section deliveries
contributing to enhanced maternal and neonatal safety. Calculate the total number of women giving birth abdominally
within the same specified time frame.

• Inclusion:
- First time cesarean section delivery: Including primigravida &
multiparous women.

• Exclusion:
- Multiparous Women: Exclude women who never delivered via
cesarean section.

Calculation: Numerator
————-——————— x 100
Denominator

Number of Cesarean Sections for the first time on pregnant

women
= —————————————————————————————————————————————— x 100
Total Number of abdominal deliveries

Sampling Benchmark

100% National Benchmark to be established through national data

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

American College of Obstetricians and Gynecologists (ACOG). Safe

prevention of the primary cesarean delivery. Obstetric Care Consensus
No. 1. Washington, DC: ACOG; 2014. Data should be collected from hospital maternity records,
Betran, A. P. et al. (2016). The Increasing Trend in Cesarean Section including patient records and delivery reports.
Rates: Global, Regional, and National Estimates: 1990–2014. PLoSONE
11(2): e0148343.

47
Name Type Code

First Medical Contact-Device Time Process SPSI.23

Definition and Rationale Calculation

Definition: Numerator: Number of Patients with acute STEMI (or its

Percentage of patients, age ≥18 years old, with acute STEMI, or equivalent) whose FMC-to-device time during primary PCI is ≤90
min.
its equivalent, who receive primary PCI during the hospital stay
with a time from FMC-to-device time ≤90 min. • Inclusion:
- All
• Exclusion:
Rationale:
- None
Primary PCI has been shown to be superior to fibrinolytic
therapy in recanalizing the infarct-related artery and imparts Denominator: All patients with acute STEMI or its equivalent who
receive primary PCI.
better clinical outcomes. The benefits of primary angioplasty
persisted during long-term follow-up and were independent of • Inclusion:
the type of fibrinolytic therapy used. - All
• Exclusion:
- Patients age <18 years old. Patients received in transfer from
the inpatient, outpatient, or ED of another facility.

Calculation: Numerator
————-——————— x 100
Denominator

Number of Patients whose FMC-to-device time during

primary PCI is ≤90 min
= —————————————————————————————————————————x 100
All patients with acute STEMI and its equivalent

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Monthly

Reference Data Collection

ACCF indicates American College of Cardiology Foundation; AHA,

American Heart Association; ED, emergency department; EMS,
emergency medical services; FMC, first medical contact; LBBB,
Medical record or other database (e.g. administrative, clinical,
left bundle branch block; MI, myocardial infarction; PCI,
registry)
percutaneous coronary intervention; STEMI, ST-elevation
myocardial infarction; and TIMI, Thrombolysis in Myocardial
Infarction.

48
Name Type Code

Door-to-Needle (DTN) Time Process SPSI.24

Definition and Rationale Calculation

Definition: Numerator: Number of Patients with acute STEMI (or its

Percentage of patients, age ≥18 years old, with acute STEMI, or equivalent) whose time from hospital arrival to fibrinolytic
therapy (DTN time) is ≤30 min.
its equivalent, who receive fibrinolytic therapy (as the primary
reperfusion modality) with a time from First Medical Contact to • Inclusion:
fibrinolysis ≤30 min. - All
• Exclusion:
Rationale: - None
It is to measure the efficiency of administering thrombolytic Denominator: All patients with acute STEMI and its equivalent.
therapy to the patients. It helps to assess how quickly patients
• Inclusion:
receive crucial treatment after arriving at the hospital, thereby
improving outcomes by minimizing delays in treatment initiation.
- All
• Exclusion:
- Patients age <18 years old. Patients received in transfer from
the inpatient, outpatient, or ED of another facility.

Calculation: Numerator
————-——————— x 100
Denominator

Number of Patients whose time from Door-to-Needle is ≤30 min

= —————————————————————————————————————————————— x 100
All patients with acute STEMI and its equivalent

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Monthly

Reference Data Collection

ACCF indicates American College of Cardiology Foundation; AHA,

American Heart Association; CABG, coronary artery bypass graft;
DTN, door-to-needle; ED, emergency department; FMC, first Medical record or other database (e.g. administrative, clinical,
medical contact; LBBB, left bundle branch block; LVEF, left
registry)
ventricular ejection fraction; MI, myocardial infarction; PCI,
percutaneous coronary intervention; and STEMI, ST-elevation
myocardial infarction.

49
Name Type Code

Ventilator-Associated Event (VAE) Rate Outcome SPSI.25

Definition and Rationale Calculation

Definition: Numerator:The number of VAEs for a location

VAEs are identified by using a combination of objective criteria: • Inclusion:
deterioration in respiratory status after a period of stability or - All patients in covered units/periods of surveillance with VAE events.
improvement on the ventilator, evidence of infection or • Exclusion:
inflammation, and laboratory evidence of respiratory infection in
a patient who was ventilated. - All patients in covered units/periods of surveillance without VAE
events
The VAE rate per 1000 ventilator-days is calculated by dividing - Patients in covered units/periods of surveillance with VAE event with
the number of VAEs by the number of ventilator-days and the date of VAE is the day of admission/transfer to the unit or day
after.
multiplying the result by 1000.
- Patients in covered units/periods of surveillance if they are on high-
frequency ventilation, extracorporeal life support, or paracorporeal
Rationale: membrane oxygenation (for full day, not partial day).
VAE including VAP events can cause excess morbidity, mortality,
Denominator: The number of ventilator days for that location
and length of stay to affected patients. Assessing the VAE rates
in different units are critical for identifying high risk units and • Inclusion:
planning potential improvement projects. - All patients on ventilator at time of daily counting in covered units/
periods of surveillance.

• Exclusion:
- All patients not on ventilator at time of daily counting in covered units/
periods of surveillance.
- Patients on non-invasive ventilation at time of daily counting in
covered units/periods of surveillance. These include non-invasive
ventilation and lung expansion devices that deliver positive pressure
to the airway (for example: CPAP, BiPAP) via non-invasive means (for
example: nasal prongs, nasal mask, full face mask, total mask, etc.)

Calculation: Numerator
———————————— x1000
Denominator

The number of VAEs

= ———————————————————————————————————————————— x 1000
The number of ventilator days for that location

Sampling Benchmark

No sampling applicable. All eligible patients in the unit during

NHSN reports (rate is different from unit to unit).
the defined month(s) of surveillance should be included.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 ventilator days. Decrease in the rate Monthly

Reference Data Collection

MOH Surveillance Manual 2nd Edition 2023. Medical Records

50
Name Type Code

Obstetric Anal Sphincter Injuries OASIS Outcome SPSI.26

Definition and Rationale Calculation

Definition: Numerator: Anal Sphincter Trauma Cases

This indicator measures the percentage of childbirths resulting Count the total number of cases where anal sphincter trauma
in anal sphincter trauma out of the total number of childbirths occurred during childbirth within a specified time frame.
within a specified time period. • Inclusion:
- Childbirth-Related Trauma: Include injuries specifically related
Rationale: to the childbirth process that affect the anal sphincter.
Anal sphincter trauma are injuries sustained during childbirth
- Diagnosed Cases: Include only those cases that are clinically
diagnosed or confirmed by healthcare professionals.
that affect anal sphincter, leading to various complications and
• Exclusion:
dysfunctions in the postpartum period.
- Non-childbirth Related Injuries: Exclude injuries or traumas not
directly linked to childbirth or those occurring due to other
factors unrelated to the birthing process.
- Unconfirmed Cases: Exclude cases that lack proper clinical
confirmation or diagnosis of anal sphincter trauma related to
childbirth.
Denominator: Total Number of Childbirths
Calculate the total number of childbirths (vaginal births or
started vaginal then converted to abdominal) within the same
specified time frame.
• Inclusion:
- All childbirths
• Exclusion:
- Cesarean deliveries
Calculation: Numerator
————-——————— x 100
Denominator

Number of Anal Sphincter Trauma Cases

=—————————————————————————————————————— x 100
Total Number of Childbirths

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

RCOG (Royal College of Obstetricians and Gynecologists). Prevention and

management of obstetric anal sphincter injuries (OASIS). Green-top
Guideline No. 29. London: RCOG; 2015. Data should be collected from maternity records, delivery
reports, and postpartum assessments to capture instances of
Jelovsek JE, Maher C, Barber MD. Pelvic Organ Prolapse. Lancet. 2007;
369 (9566):1027-1038.
obstetric anal sphincter injuries.

51
Name Type Code

Perioperative Mortality Rate (POMR) Outcome SPSI.27

Definition and Rationale Calculation

Definition: Numerator: Number of deaths among patients having one or more

procedures in an operating theatre during the relevant admission
It is defined as the rate of death following surgery and
anesthesia either on the day of surgery, before the 30th • Inclusion:
postoperative day or on the day of discharge from the hospital. - All deaths that occur in the hospital following surgery and anesthesia
on the day of surgery.
- Deaths that occur within 30 days post-operation, regardless of the
Rationale: patient's location (in hospital or discharged).
POMR is inversely correlated with the improvement in access to - Deaths related directly to the surgical procedure and anesthesia.
advanced anesthesia care and surgical services. • Exclusion:
- Deaths unrelated to the surgical procedure or anesthesia (e.g., pre-
existing conditions not exacerbated by surgery).
- Deaths occurring more than 30 days post-operation.
- Patients who were admitted with a terminal illness where death within
30 days was expected regardless of surgical intervention.
Denominator: The number of ventilator days for that location

• Inclusion:
- All surgical procedures performed in an operating theatre that require
general or regional anesthesia.
- Emergency and elective surgical procedures.
• Exclusion:
- Non-surgical or minor procedures not requiring anesthesia or only
requiring local anesthesia (e.g., minor dermatological procedures).

Calculation: Numerator
———————————— x 1,000
Denominator

Number of deaths
= —————————————————————————————— x 1,000
Total number of surgical procedures

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 1,000 procedures. Decrease in the rate Annually

Reference Data Collection

Perioperative Mortality Rate, World Health Organization (WHO).

Data can be collected from medical records, including discharge
2015 Global Reference List of 100 Core Health Indicators.;
summaries.
2015.

52
Name Type Code

Proportion of Sepsis patients who received early

management bundle Process SPSI.28

Definition and Rationale Calculation

Definition: Numerator: Number of patients who started first dose of an

This measure focuses Proportion of patients (≥ 14 years old) empirical antimicrobial within 60 min of recognition of sepsis.
with sepsis who started their first dose of an empirical • Inclusion:
antimicrobial within 60 minutes of recognition. - Patients who received ALL the following (screening of lactate,
obtaining blood cultures, administering an empirical
antimicrobial) within one hours of recognition.
Rationale: • Exclusion:
Prompt administration of empirical antimicrobials within 60 - None
minutes of recognizing sepsis is crucial for improving patient Denominator: Total number of patients with provisional diagnosis
outcomes. Early intervention is associated with reduced of sepsis (infection and at least one organ/system dysfunction).
mortality and morbidity, emphasizing the importance of timely
sepsis management. • Inclusion:
- All patient more than 14 years old with signs and symptoms
suggesting sepsis.
• Exclusion:
- None
Calculation: Numerator
———————————— x 100
Denominator

Number of patients who received early management bundle

= —————————————————————————————————————————————— x 100
Total number of patients with provisional diagnosis of sepsis

Sampling Benchmark

National Benchmark to be established through national data.

100%
AHRQ: %95

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Increase in the percentage Quarterly

Reference Data Collection

Australian commission on safety and quality in health care,

Data can be collected from medical records.
standard 30/6/2022

53
Name Type Code

Multi Drug Resistant Organism Rate Outcome SPSI.29

Definition and Rationale Calculation

Definition: Numerator: The number of specimens with positive non-

duplicate MDRO.
MDROs are defined any specimen, obtained for clinical decision
making, testing positive for an MDRO resistant to one or more • Inclusion:
classes of antimicrobial agents. All specimens with positive non-duplicate MDRO
- An MDRO isolated from blood in a patient with no prior positive blood
MDRO infection incidence rate is calculated by dividing the culture for the same MDRO within 14 days.
number of infections of a certain MDRO type by the number of
- An MDRO isolated from a non-blood sample in a patient with no prior
patient days and multiplying the results by 1000. positive blood culture for the same MDRO within the same calender
month.
Rationale: • Exclusion:
Antimicrobial resistance can cause death and disability of - Duplicate MDRO specimens
treated patients due to limited therapeutic options. Additionally, - Non-clinical specimens (active surveillance testing).
it has a significant economic impact on healthcare facility and Denominator: All patients admitted to the units/periods covered by
community. Assessing the MDRO rates of different bacteria in MDRO surveillance
different units are critical for identifying high risk units/ • Inclusion:
organisms and planning potential improvement projects.
- All patients admitted to the units/periods covered by MDRO
surveillance.
• Exclusion:
- None
Calculation: Numerator
———————————— x 10,000
Denominator

The number of infections of a certain MDRO type

= ———————————————————————————————————— x 10,000
The number of patient days

Sampling Benchmark

No sampling applicable. All patients with tested non-duplicate

clinical specimens in the covered unit during the defined NHSN reports (rate is different from MDRO type to another)
month(s) of surveillance should be included.

Unit of Measure Improvement Noted As Reporting Frequency

Rate per 10,000 patient days. Decrease in the rate Monthly

Reference Data Collection

MOH Surveillance Manual 2nd Edition 2023 Medical and laboratory records

54
Name Type Code

Pregnant women that have a minimum of 8 ANC visits

starting before 14 weeks of pregnancy. Process SPSI.30

Indicator Definition and Rationale Calculation

Definition: Numerator: Number of Pregnant Women Receiving 8 Recommended

ANC visits starting from first trimester.
It is a key indicator used in healthcare to assess the timely
Count the number of pregnant women who have attended the minimum
initiation of prenatal care by measuring the proportion of number of recommended antenatal care visits starting from first
pregnant women who have attended a clinic or healthcare trimester as per the established guidelines or standards.
facility for antenatal care during the first trimester of • Inclusion:
pregnancy. - Recommended ANC Visits: Include pregnant women who have attended
the minimum number of 8 recommended antenatal care visits starting
from first trimester as per MOH established guidelines
Rationale:
• Exclusion:
Tracking the proportion of pregnant women initiating antenatal - Attending only first trimester visit, or not the recommended minimum
visits in their first trimester provides valuable insights into number of 8 visits.
access to healthcare services, early identification of pregnancy- - Attending the recommended minimum number of 8 visits, but not
related risks, and the opportunity for early interventions to starting at first trimester.
promote safe pregnancies and healthy outcomes for both Denominator: Total Number of Pregnant Women
mothers and infants. Count the total number of pregnant women within a specific population
or cohort during a defined time period.
• Inclusion:
- Pregnant Women Under Observation: Include all pregnant women
within the specific population or cohort under observation during the
defined time period.
• Exclusion:
- Non-Pregnant Individuals: Exclude women who are not pregnant during
the specified time frame. This criterion ensures that only pregnant
women are considered for ANC coverage calculation.
- Missing Data: Exclude pregnant women from the numerator and
denominator if their data regarding antenatal care visits is missing or
incomplete, and it cannot be verified if they met the minimum
recommended of 8 visits.
- Pregnancies with Unknown Outcomes: Exclude pregnancies with
unknown outcomes or those ending in miscarriage, termination, or
stillbirth before the minimum recommended ANC visits are completed.
Calculation: Numerator
———————————— x 100
Denominator
Number of Pregnant Women that have visited the clinic in their
1st trimester & completed recommended ANC Visits of 8
= ————————————————————————————————————————————— x 100
Total Number of Pregnant Women

Sampling Benchmark

100% National Benchmark to be established through national data.

Unit of Measure Improvement Noted As Reporting Frequency

Percentage Decrease in the percentage Monthly

Reference Data Collection

World Health Organization. New guidelines on antenatal care for a

positive pregnancy experience. November 7, 2016. Accessed 12/ 12/ Data should be collected from maternity clinic or healthcare
2023 https://www.who.int/news/item/07-11-2016-new-guidelines-on- facility records to capture instances where pregnant women
antenatal-care-for-a-positive-pregnancy-experience
initiate antenatal care during their first trimester. This
Centers for Disease Control and Prevention (CDC). Recommendations for
Providing Quality Prenatal Care. Atlanta, GA: CDC; [Accessed January information includes visit dates and completion of the
2022]. Available from: https://www.cdc.gov/mmwr/volumes/66/rr/ minimum recommended antenatal care visits.
rr6601a1.htm

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