HIM Leadership with Patient Safety Indicators (PSIs)

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Since the year 2000, there has been an increasing focus on quality and outcomes in healthcare, particularly in acute care hospitals. The Agency for Healthcare Research and Quality or AHRQ developed and initiated clinical quality measures in 2003, now called Patient Safety Indicators or PSIs. The quality measures demographics, specific coded data and as such the Health Information Management leaders need to know and understand PSIs. The Centers for Medicare and Medicaid Services (CMS) has supported having the PSIs in place through “Hospital Compare” and have a dedicated website to more information: https://qualitynet.cms.gov/inpatient/measures/psi/resources

Back in 2000, a pivotal article was published by Institute of Medicine titled, “To Err is Human”. In this article, it was estimated that possibly 98,000 people die each year from medical errors that occur in acute care hospitals. These errors were often preventable if the correct checks and balances were in place. Back then, statistics showed that this was higher those who die from motor vehicle accident, breast cancer or AIDS. Under the Agency Research and quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), patient safety indicators were developed for acute care hospitals which launched a huge effort towards quality of care.

Patient Safety Indicators, abbreviated as PSIs, were developed with a primary focus on preventable in-hospital complications and adverse events that can occur after surgeries, medical procedures, and childbirth. PSIs are based upon comprehensive literature, analysis of available ICD codes, a review by clinical panels, empirical analyses, and risk adjustment.

Because PSIs often include hospital complications of care or surgery care, accurate ICD-10-CM/PCS coding is vital. Let’s take a look at three PSIs:

PSI 03: Pressure Ulcer

Description: Pressure ulcers that develop after admission.

Numerator: Any secondary diagnosis for Stage 3,4, or unstageable pressure ulcer POA=N


  1. If principal diagnosis or secondary diagnosis POA=Y
  2. Any diagnosis code for severe burns or exfoliative disorders of the skin (≥ 20% body surface area)
  3. LOS < 3 days

PSI 06: Latrogenic Pneumothorax

Description: Iatrogenic/postprocedure pneumothorax that develops after admission.

Numerator: Secondary diagnosis of postprocedural (iatrogenic) pneumothorax with POA= N


  1. If principal diagnosis or secondary diagnosis POA=Y
  2. Chest trauma (rib fractures, traumatic pneumothorax, chest wall injuries, or pleural effusion)
  3. Thoracic surgery, including lung or pleural biopsy, or diaphragmatic repair
  4. Potentially trans-pleural cardiac procedure (CABG, etc.)

PSI 08: In Hospital Fall with Hip Fracture

Description: Hospital falls that result in a hip fracture

Numerator: Any secondary diagnosis for hip fracture with POA = N


Hip fracture POA=Y • Hip fracture associated with joint prosthesis

The ICD-10-CM/PCS codes behind each PSI is something HIM leaders should regularly review and discuss. The review of inpatient PSIs that occur should be in place and occur in a very timely manner. This means it would include staff from “Quality” along with a HIM coding professional or two (depending on the size of the hospital or organization).

A terrific site to visit regarding PSIs is the Agency for Healthcare Research and Quality (AHRQ), AHRQ QI: Patient Safety Indicators Overview

Per the AHRQ Patient Safety Indicators:

  • Can be used to help hospitals and health care organizations assess, monitor, track, and improve the safety of inpatient care.
  • Can be used for comparative public reporting, trending, and pay-for-performance initiatives.
  • Can identify potentially avoidable complications that result from a patient’s exposure to the health care system.
  • Include hospital-level indicators to detect potential safety problems that occur during a patient’s hospital stay.
  • Include area-level indicators for potentially preventable adverse events that occur during a hospital stay to help assess total incidence within a region.
  • Are publicly available at no charge to the user.
  • Include risk adjustment where appropriate.

The ICD-10-CM Official Guidelines for Coding and Reporting, tell us, “There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant.” This is an extremely important guidance to be followed and adhered to.

The following is a full list of PSIs:

  • PSI 02 – Death rate in low-mortality diagnosis related groups (DRGs)
  • PSI 03 – Pressure ulcer rate
  • PSI 04 – Death rate among surgical inpatients with serious treatable conditions
  • PSI 05 – Retained surgical item or unretrieved device fragment count
  • PSI 06 – Iatrogenic pneumothorax rate
  • PSI 07 – Central venous catheter-related blood stream infection rate
  • PSI 08 – In hospital fall with hip fracture
  • PSI 09 – Perioperative hemorrhage or hematoma rate
  • PSI 10 – Postoperative physiologic and metabolic derangement rate
  • PSI 11 – Postoperative respiratory failure rate
  • PSI 12 – Perioperative pulmonary embolism or deep vein thrombosis rate
  • PSI 13 – Postoperative sepsis rate
  • PSI 14 – Postoperative wound dehiscence rate
  • PSI 15 – Accidental puncture or laceration rate
  • PSI 17 – Birth trauma rate – injury to neonate
  • PSI 18 – Obstetric trauma rate – vaginal delivery with instrument
  • PSI 19 – Obstetric trauma rate-vaginal delivery without instrument
  • PSI 90 – Patient Safety for Selected Indicators

PSIs are reviewed and revised by AHRQ and thus ICD-10-CM codes that are included in a particular PSI can also be changed. Having collaboration between the hospital quality and HIM departments is certainly a best practice to have in place.

The health information management professionals and in particular medical coding professionals should take a look at the at information posted on the AHRQ website and become very familiar with PSIs, the documentation and coding: https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2023/ChangeLog_PSI_v2023.pdf

References: CMS.gov: Patient Safety Indicators (PSI) 2024 Resources; AHRQ: Patient Safety Indicators (PSI) Log of Coding Updates and Revisions; PSNet: Patient Safety Indicators Overview

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