Patient Safety Overview & Forms

The Patient Safety Surveillance and Improvement System (PSSIS) was created for the purpose of improving patient safety, eliminating adverse events in Vermont hospitals, and supporting, and facilitating quality improvement efforts by hospitals. The Vermont Department of Health is charged by statute to operate the PSSIS, and contracts with the Vermont Program for Quality in Health Care (VPQHC) to administer the System.

  • According to State statute (PSSIS Rule), each Vermont hospital must:
    • establish internal policies and procedures to identify, track and analyze all adverse events and near misses.
    • conduct appropriate causal analysis.
    • develop and implement corrective action plans.
  • Each hospital must report any incidence of intentional unsafe acts.
  • Each hospital must develop policies and procedures requiring disclosure to patients relating to adverse events that cause death or serious bodily injury.

Patient Safety/ICD-10 Codes

For those of you using discharge codes to track or identify events or for other identification reasons, this document has proven to be extremely beneficial.

The first few pages are specific to the “Neighborhood Health Plan” reimbursement rules, however starting with page 5, many of the SREs are listed along with the corresponding ICD-10 code. It should be noted that not all SREs are included and that the list contains other “preventable events” and HAIs.

Some other important lessons from the 1650+ page ICD-10 manual:

  • You may want to connect with the coding staff at your facility to verify that there are not other/better codes to identify what you are looking for.
  • ICD-10 includes a section relative to “Place of Occurrence” that can be used to indicate the hospital (Y92.239) or a more specific place within the hospital, such as hallway (Y92.232), O.R. (Y92.234), and pt room/bathroom (Y92.230) that might be useful to search specifically for events that occur in-house, i.e. falls.
  • There are also “Place of Occurrence” codes specific to the ambulatory setting (Y92.53, Y92.530, 531, 532, 538) that might be worth a look.

 If you have any further questions or other helpful resources, feel free to contact Sue at