PSI 90

PSI 90: Understanding the Key Patient Safety Indicators for Hospital Performance

PSI 90: Understanding the Key Patient Safety Indicators for Hospital Performance

What Is PSI 90?

PSI 90, officially known as the Patient Safety and Adverse Events Composite, is a critical measure used to evaluate hospital safety and quality. Developed by the Agency for Healthcare Research and Quality (AHRQ), it combines multiple Patient Safety Indicators (PSIs) into a single score, helping healthcare organizations assess preventable complications that occur during hospital stays.

Essentially, PSI 90 acts as a hospital safety report card, tracking issues like post-surgical infections, blood clots, and complications that could have been avoided with better care. It’s widely used in Medicare’s Hospital Value-Based Purchasing (VBP) Program, which means hospitals with poor PSI 90 scores can face financial penalties, while those with strong performance may receive higher reimbursements.

Why Does PSI 90 Matter?

  • It Highlights Preventable Harm – The composite score focuses on adverse events that hospitals should work to reduce, from post-op blood clots to pressure ulcers.
  • It Impacts Hospital Reimbursement – Medicare ties PSI 90 performance to payment adjustments, making it a financial incentive to improve patient safety.
  • It Influences Public Perception – PSI 90 scores contribute to hospital rankings and can impact patient trust in a facility’s quality of care.

By understanding PSI 90, hospitals can pinpoint safety gaps, implement targeted improvements, and ultimately enhance patient outcomes.

AHRQ and the Development of PSI 90

The Agency for Healthcare Research and Quality (AHRQ) is the driving force behind PSI 90 and other Patient Safety Indicators (PSIs). As a federal agency within the U.S. Department of Health and Human Services (HHS), AHRQ focuses on improving healthcare quality, safety, efficiency, and effectiveness.

PSI 90 - Development

How AHRQ Developed PSI 90

AHRQ created PSIs as standardized measures to help hospitals identify preventable complications and medical errors. The PSI framework was developed using data from administrative hospital records, allowing facilities to track patient safety events consistently across different healthcare settings.

PSI 90 was introduced as a composite measure to:

  • Streamline hospital safety evaluation by combining multiple individual PSIs into a single, more actionable score.
  • Enhance risk adjustment, ensuring hospitals are fairly compared by considering patient severity and case complexity.
  • Align with federal quality programs, such as Medicare’s Hospital-Acquired Condition (HAC) Reduction Program and Value-Based Purchasing (VBP) Program.

How AHRQ Uses PSI 90 for Quality Improvement

AHRQ provides guidelines, research, and technical assistance to help hospitals use PSI 90 effectively. Key initiatives include:

  • Publishing PSI methodology updates to improve accuracy and reliability.
  • Offering benchmarking data so hospitals can compare their PSI 90 performance against national averages.
  • Providing patient safety toolkits to help hospitals reduce preventable adverse events and improve care quality.

By establishing PSI 90 as a core patient safety measure, AHRQ has given hospitals a powerful tool to track progress, identify risks, and improve overall patient outcomes.



What Does PSI 90 Measure?

The following individual indicators make up PSI 90. Each represents a different type of patient safety event that hospitals should monitor and prevent.

PSI 03 – Pressure Ulcers (Bedsores) Stage 3+

  • Tracks severe pressure ulcers (bedsores) that develop in hospitalized patients.
  • Indicates issues with prolonged immobility, inadequate repositioning, or poor skin care.
  • Prevention strategies: Frequent repositioning, specialized mattresses, and early intervention.

PSI 06 – Iatrogenic Pneumothorax

  • Measures lung collapse caused by medical procedures, such as central line insertion or mechanical ventilation.
  • Suggests potential errors in technique or failure to recognize high-risk patients.
  • Prevention strategies: Ultrasound guidance for procedures, proper insertion techniques, and close monitoring.

PSI 08 – Postoperative Hip Fracture

  • Tracks hip fractures occurring in hospitalized surgical patients.
  • Often linked to falls due to poor mobility assessments or lack of fall prevention protocols.
  • Prevention strategies: Fall risk screenings, bed alarms, and mobility assistance.

PSI 09 – Perioperative Hemorrhage or Hematoma

  • Measures severe bleeding or hematomas occurring after surgery.
  • Often related to surgical errors, improper anticoagulation management, or failure to control bleeding during procedures.
  • Prevention strategies: Careful monitoring of anticoagulant use, improved surgical techniques, and postoperative observation.

PSI 10 – Postoperative Acute Kidney Injury (AKI) Requiring Dialysis

  • Tracks severe kidney injury that requires dialysis after surgery.
  • Indicates possible issues with fluid management, nephrotoxic medication use, or prolonged hypotension.
  • Prevention strategies: Hydration protocols, avoiding nephrotoxic drugs, and early detection of kidney dysfunction.

PSI 11 – Postoperative Respiratory Failure

  • Measures cases where patients require prolonged mechanical ventilation or reintubation after surgery.
  • Suggests issues with anesthesia management, lung complications, or delayed postoperative care.
  • Prevention strategies: Preoperative pulmonary assessments, use of incentive spirometry, and close postoperative monitoring.

PSI 12 – Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)

  • Tracks blood clots that develop after surgery, which can be life-threatening if untreated.
  • Suggests failures in early mobility, anticoagulation therapy, or patient monitoring.
  • Prevention strategies: Blood thinners, compression devices, and early ambulation.

PSI 13 – Postoperative Sepsis

  • Measures life-threatening infections that develop after surgery.
  • Indicates issues with sterile surgical techniques, infection control, or failure to recognize early signs of sepsis.
  • Prevention strategies: Strict adherence to surgical sterility, early antibiotic use, and rapid treatment of sepsis symptoms.

PSI 14 – Postoperative Wound Dehiscence

  • Tracks cases where surgical wounds reopen after abdominal or pelvic surgery.
  • Often linked to poor wound healing, excessive tension on sutures, or infections.
  • Prevention strategies: Proper suture techniques, infection prevention protocols, and careful postoperative movement restrictions.

PSI 15 – Accidental Puncture or Laceration

  • Tracks unintentional cuts or punctures during medical procedures.
  • Suggests possible surgical or procedural errors.
  • Prevention strategies: Enhanced training for surgical teams, use of real-time imaging during procedures, and careful handling of surgical instruments.

Why These Indicators Matter

  • They Represent Preventable Harm – PSI 90 focuses on complications that can often be avoided with better hospital protocols.
  • They Impact Hospital Performance Metrics – A high PSI 90 score can lead to lower reimbursement rates and public reporting penalties.
  • They Drive Quality Improvement Efforts – Hospitals use PSI 90 data to implement safety initiatives, train staff, and enhance patient care protocols.

By monitoring these key PSI 90 components, hospitals can reduce preventable harm, improve patient outcomes, and maintain financial stability in value-based care models.

PSI 90 - Data

Other Key Patient Safety Indicators to Know

While PSI 90 includes a composite of key safety measures, there are additional Patient Safety Indicators (PSIs) that hospitals track separately. These indicators provide further insights into hospital safety and highlight areas for improvement beyond what is covered in PSI 90.

Here are some of the most notable PSIs that are not part of PSI 90:

PSI 02 – Death in Low-Mortality Diagnosis-Related Groups (DRGs)

  • Measures unexpected inpatient deaths in cases where patients were not initially expected to have a high risk of mortality.
  • Often linked to medical errors, delays in diagnosis, or inadequate monitoring.
  • Why it matters: Helps identify systemic failures in hospital care, particularly in lower-risk patient groups.

PSI 04 – Death Among Surgical Inpatients with Serious Treatable Complications

  • Tracks mortality rates for surgical patients who develop complications that are normally treatable.
  • Includes conditions such as sepsis, shock, and cardiac arrest post-surgery.
  • Why it matters: A high rate of avoidable deaths signals gaps in postoperative monitoring and response.

PSI 16 – Transfusion Reaction

  • Measures the rate of serious adverse reactions to blood transfusions.
  • Includes hemolytic reactions, improper blood matching, and contamination issues.
  • Why it matters: Indicates errors in blood management protocols and potential patient safety risks.

PSI 17 – Birth Trauma – Injury to Neonate

  • Tracks birth-related injuries to newborns, such as skull fractures, nerve damage, or intracranial hemorrhages.
  • Often linked to delivery complications, improper use of forceps, or delays in emergency intervention.
  • Why it matters: Highlights obstetric safety concerns and opportunities to improve labor and delivery protocols.




 

PSI 18 – Obstetric Trauma – Vaginal Delivery with Instrument Assistance

  • Measures injuries to the mother during vaginal deliveries that involve the use of forceps or vacuum extraction.
  • Includes severe perineal lacerations, excessive bleeding, and other complications.
  • Why it matters: Tracks avoidable maternal injuries and informs safer obstetric care practices.

PSI 19 – Obstetric Trauma – Vaginal Delivery without Instrument Assistance

  • Similar to PSI 18, but focuses on maternal injuries occurring in vaginal deliveries without forceps or vacuum extraction.
  • Helps hospitals identify whether better labor support and delivery techniques can reduce trauma rates.

PSI 22 – Perioperative Venous Thromboembolism (VTE) Prevention Failure Rate

  • Tracks how often hospitals fail to provide appropriate VTE prevention for surgical patients.
  • Includes missed use of blood thinners, compression devices, or early ambulation strategies.
  • Why it matters: Helps pinpoint hospital failures in preventing preventable blood clots post-surgery.

Why These PSIs Matter

  • They Cover Critical Safety Gaps – These indicators highlight preventable harm in areas not captured by PSI 90.
  • They Help Address High-Risk Patient Groups – Birth trauma, transfusion reactions, and unexpected mortality require specialized patient safety strategies.
  • They Support Broader Hospital Safety Goals – Tracking these PSIs helps hospitals improve protocols, refine training, and enhance overall quality of care.

By monitoring PSIs beyond PSI 90, hospitals can further reduce patient harm, enhance safety protocols, and improve overall quality ratings.

The Broader Impact of PSI 90 in Healthcare

PSI 90 isn’t just a measure of patient safety—it plays a direct role in hospital funding, public reputation, and healthcare policy. Hospitals that fail to control PSI 90-related complications may face financial penalties, lower rankings, and reduced patient trust.

PSI 90 and Medicare Reimbursement

  • PSI 90 is used in the Medicare Hospital-Acquired Condition (HAC) Reduction Program and Value-Based Purchasing (VBP) Program to determine hospital penalties and financial incentives.
  • Hospitals with poor PSI 90 scores can lose up to 1% of their total Medicare payments, significantly impacting their financial stability.
  • Facilities that perform well on PSI 90 may receive higher reimbursement rates and avoid penalties.

PSI 90’s Role in Public Reporting and Rankings

  • CMS Hospital Compare publishes PSI 90 data, allowing patients to compare hospitals based on safety performance.
  • The Leapfrog Group and U.S. News & World Report also consider PSI scores in their hospital safety rankings.
  • Hospitals with high PSI 90 scores risk reputational damage, potentially losing patients to better-rated facilities.

PSI 90 and Healthcare Accountability

  • PSI 90 pushes hospitals to enhance patient safety by making adverse event rates more transparent.
  • Regulatory agencies use PSI 90 to track hospital performance, ensuring quality improvement efforts remain a priority.
  • Hospitals that effectively reduce PSI 90-related events not only improve patient care but also gain a competitive advantage in the industry.

By recognizing PSI 90’s financial, reputational, and regulatory implications, hospitals can better align their safety strategies with broader healthcare goals.

Challenges and Limitations of PSI Metrics

While PSI 90 and other Patient Safety Indicators (PSIs) play a crucial role in improving hospital safety, they are not without challenges. Hospitals, policymakers, and healthcare professionals must navigate data accuracy issues, risk adjustment complexities, and potential unintended consequences when using PSI metrics.

Potential Issues with Data Accuracy and Risk Adjustment

  • Hospitals rely on administrative data, which can sometimes lack clinical detail or be subject to coding errors.
  • Risk adjustment limitations make it difficult to fairly compare hospitals, as some facilities treat sicker, higher-risk patient populations.
  • Overreporting or underreporting of PSI events due to variation in documentation practices can skew results.

How Hospitals Can Manipulate PSI Rates Through Documentation Practices

  • Coding practices can impact PSI scores, as hospitals may document complications differently to avoid financial penalties.
  • Some hospitals may reclassify patient conditions to exclude cases from PSI calculations, artificially improving their scores.
  • Electronic Health Records (EHRs) and AI-assisted coding may introduce inconsistent data reporting, affecting PSI accuracy.

The Balance Between Improving Safety and Avoiding Punitive Measures

  • Financial penalties tied to PSI 90 can disproportionately affect safety-net hospitals that care for more complex, high-risk patients.
  • Hospitals may focus on “gaming the system” rather than genuinely improving patient care if PSI metrics are used too rigidly in reimbursement models.
  • There is an ongoing debate about whether PSI 90 should be adjusted further to reflect socioeconomic and patient complexity factors.

Navigating the Challenges

Despite these limitations, PSI 90 remains a valuable tool for patient safety improvement. Ensuring accurate reporting, meaningful quality improvement efforts, and fair evaluation criteria can help hospitals use PSIs effectively without creating unintended consequences.

Improving Patient Safety Through PSI Monitoring

To reduce adverse events and improve patient safety, hospitals must go beyond simply tracking PSI 90 and other Patient Safety Indicators (PSIs)—they must implement proactive strategies that drive meaningful change. By leveraging data analytics, staff training, and targeted interventions, healthcare organizations can minimize preventable complications and enhance overall quality of care.

How Hospitals Can Reduce PSI-Related Adverse Events

  • Strengthening clinical protocols to prevent common PSI 90 events, such as pressure ulcers, postoperative blood clots, and surgical site infections.
  • Enhancing early detection systems through real-time monitoring and predictive analytics to identify high-risk patients before complications occur.
  • Implementing multidisciplinary safety teams to regularly review PSI data and develop hospital-wide improvement plans.

Best Practices for Preventing PSI 90-Related Complications

  • Standardized Care Bundles – Adopting evidence-based protocols for conditions like postoperative sepsis and venous thromboembolism (VTE).
  • Fall Prevention Programs – Conducting fall risk screenings and utilizing bed alarms, mobility assistance, and staff training to reduce hip fractures (PSI 08).
  • Pressure Ulcer Prevention – Implementing turning schedules, skin assessments, and specialized support surfaces to prevent severe bedsores (PSI 03).
  • Improved Procedural Techniques – Reducing iatrogenic pneumothorax (PSI 06) by ensuring ultrasound-guided procedures and competency-based training.

The Role of Technology, Data Analytics, and Staff Training in Patient Safety

  • Electronic Health Records (EHRs) & AI Analytics – Using predictive modeling and real-time dashboards to identify trends in PSI events.
  • Automated Alerts & Clinical Decision Support Systems – Providing real-time warnings for conditions like sepsis risk or postoperative respiratory failure.
  • Continuous Staff Education – Ensuring clinicians, nurses, and hospital staff receive ongoing training on PSI prevention strategies and reporting accuracy.

By implementing targeted interventions and leveraging data-driven insights, hospitals can significantly reduce PSI-related harm, improve patient safety, and enhance financial performance in value-based care models.

Final Notes

Patient Safety Indicators (PSIs), particularly PSI 90, are essential tools for evaluating and improving hospital safety. By tracking preventable complications such as pressure ulcers, postoperative infections, and surgical errors, hospitals can identify areas for improvement and implement targeted strategies to enhance patient care.

Key Takeaways:

  • PSI 90 directly impacts hospital performance and reimbursement. Medicare uses it as part of the Hospital-Acquired Condition (HAC) Reduction Program and Value-Based Purchasing (VBP) Program, where poor scores can result in financial penalties.
  • Public reporting makes PSI 90 a critical measure for hospital reputation. Patients, regulatory agencies, and ranking organizations use these scores to assess hospital quality and safety.
  • Challenges in PSI reporting exist, including data accuracy concerns, risk adjustment limitations, and variations in documentation practices.
  • Hospitals can improve PSI performance by leveraging data analytics, staff training, and evidence-based protocols to reduce preventable adverse events.

By prioritizing PSI monitoring and continuous quality improvement, healthcare organizations can reduce preventable harm, enhance patient safety, and strengthen overall hospital performance.

For those seeking additional information on PSI 90 and patient safety indicators:

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