Executive Summary ChecklistObstetric Hemorrhage is the most common complication in pregnancy leading to severe maternal morbidity and preventable mortality.  The National Partnership for Maternal Safety, an alliance of the professional organizations of maternity care professionals and advocates, selected this safety topic for priority development and national implementation.  Representative experts from these organizations developed the bundle to outline critical clinical practices that should be implemented in every maternity unit. To underscore the importance of this work. In depth description of this bundle has been simultaneously published in 5 peer reviewed journals representing the involved organizations.  As will all maternal safety bundles, the Obstetric Hemorrhage bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources to assist with implementation. (http://www.safehealthcareforeverywoman.org/)Prevention of PPH-related maternal mortalityCommitment from hospital governance and senior administrative leadership to support maternal safety initiatives like PPH in their healthcare system.Readiness in Every UnitCreate a hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches based on the recommendations referenced \cite{2006,safemotherhood,ob3,american2014preparing,collaborative2013florida,postpartum18hemorrhage,bingham2010cmqcc}Ensure teams have immediate access to hemorrhage medications (kit or equivalent) \cite{world2014recommendations,evanson2014postpartum,warningguidelines}Establish a response team - who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services)\cite{joint2010sentinel}Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)Unit education on protocols, unit-based drills (with post-drill debriefs)Recognition & Prevention in Every PatientAssessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)Assessment of:Retained placentaFailure to progress during the second stageLacerationsMorbidly adherent placentaInstrumental deliveryLarge for gestational age newborn (>4000 gm)Hypertensive disordersInduction of laborProlonged 1st or second stage of laborMeasurement of cumulative blood loss (formal, as quantitative as possible)Weigh the pads for quantitative measurementActive management of the 3rd stage of labor (department-wide protocol)ResponseUnit-standard, stage-based, obstetric hemorrhage emergency management plan with checklistsObstetric rapid response teams, Team Stepps.Support program for patients, families, and staff for all significant hemorrhagesReportingEstablish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunitiesMultidisciplinary review of serious hemorrhages for systems issuesMonitor outcomes and process metrics in perinatal quality improvement (QI) committeeThe Performance GapGlobal maternal deaths have fallen 44% since 1990 but still over 303,000 women die each year from complications related to pregnancy, delivery, or within the first six weeks after delivery \cite{world44a}. A majority of deaths (64%) occur from the day of delivery through 41 days postpartum \cite{Creanga_2015}. That equates to about 830 women dying every day, 550 occurring in sub-Saharan Africa, 180 in Southern Asia, and 5 in developed countries \cite{world2016global}.Within the United States it is estimated that approximately 600 women die each year \cite{ob15}; 14.0 per 100,000 live births \cite{world2015trends}. While that number seems to pale in comparison on the global scale the US ranks 46th in the world for maternal mortality \cite{ob17}. Of all industrialized countries, the US lags behind Kazakhstan, Libya and Qatar and is one of only 13 countries whose rates have continued to decline instead of improving over the last 25 years \cite{ob18}.A 2015 report by the United Nations (UN) agencies and World Bank Group, Trends in Maternal Mortality: 1990 to 2015, was generated to gauge whether the UN’s Millennium Development Goals would be reached.5 The 2015 target was to reduce maternal mortality by three-quarters. Only 9 of the 100 countries participating reached the 2015 goal so the new target is to reduce global average maternal death rates below 70 per 100,000 live births by the year 2030, with no country above 140 per 100,000 live births.1The reasons for the overall increase in maternal mortality within the US are unclear. Delaying childbearing and assisted reproductive technology (ie: in-vitro fertilization) have given rise to older mothers with an increased risk of complications than younger women \cite{Jolly_2000,Bewley_2005}. Additionally, the obesity epidemic gives rise to chronic conditions such as hypertension, diabetes, and chronic heart disease increase the risk of complications during pregnancy \cite{centers2015pregnancy,Kuklina_2009,Albrecht_2010,Kuklina_2012}.Over a third of maternal deaths in the US are preventable, 40% could be avoided if women had access to quality care \cite{Berg_2005}. Most notably, black women have a 3 to 4-fold increased risk of death due to pregnancy compared to any other race or ethnicity \cite{creanga2014racial}. The reasons are extremely complex and not well documented. Moreover, severe maternal morbidity is much more prevalent and preventable, affecting tens of thousands of women each year \cite{Callaghan_2012,Callaghan_2008}.Postpartum Hemorrhage (PPH)Obstetric hemorrhage remains among the leading global causes of severe maternal morbidity and mortality \cite{Callaghan_2010,Calvert_2012,Cristina_Rossi_2012}. In some developing countries, the maternal mortality rate is as high as 1 percent of live births with nearly one-fourth of those deaths being attributable to postpartum hemorrhage (PPH)\cite{abouzahr1998antepartum}. According to the most recent mortality data reported to the CDC in 2011-2012, 11% of pregnancy-related deaths in the U.S. are caused by PP \cite{BERG_1996}. Between 1994-2006, the number of PPH cases has increased more than 25 percent, potentially driven by a 50 percent increase in uterine atony.PPH is a "low-volume, high-risk" event for birth facilities, which has led to the down-prioritization for developing standardized intervention protocol\cite{lyndon2015improving}. Limited consideration for the implementation of coordinated approaches persists despite a consistent global recognition that the lack of communication, patient engagement, and clinical intervention strategies for managing acute hemorrhage in the postpartum period lead to an increase in maternal morbidity and mortality \cite{mander2008saving,ob36}.There are many potential causes for PPH, but chief among them is uterine atony or the inability of the uterus to contract and retract following childbirth. PPH in a previous pregnancy also can increase the risk of hemorrhage during a subsequent delivery. A contributing factor to the lack of standard coordinated approaches to PPH is the issue that there is no precise definition for the condition. Literature defines PPH as blood loss of more than 500 mL following a vaginal delivery or more than 1000 mL following a cesarean section delivery.28,\cite{ob37} PPH is also classified by time frame with Primary PPH occurring in the first twenty-four hours and secondary or late-term PPH occurring in the subsequent period. Further, blood loss during delivery can be difficult to measure, which is attributable to lack of standardization on how to manage blood collected during childbirth as well as improvements in medical products that can absorb a deceivingly high amount of fluid. The lack of clear guidelines for measuring blood loss during childbirth often leads to underestimation and a clinician may not diagnose Primary PPH.Population-based studies have identified some significant risk factors that may result in PPH:Retained PlacentaFailure to Progress During the Second Stage Of LaborPlacenta Accreta, Increta, and PercretaLacerationsInstrumental DeliveryLarge Gestational Age (LGA) NewbornsHypertensive DisordersInduced LaborAugmentation of Labor With Oxytocin \cite{16272036}Another issue that leads to the missed diagnosis of PPH is the physiological difference between expectant mothers. On average, mothers of single pregnancies have between 30-50 percent higher blood volume than a non-pregnant woman. Within the pregnant population, other blood-related physiological traits such as anemia, underlying cardiac conditions, or preeclampsia will also impact a mother's ability to tolerate blood loss.Lack of timely and medically appropriate response to PPH is what results in poor outcomes. Early recognition of PPH and a timely, coordinated intervention are essential to reducing associated morbidity and mortality.Leadership PlanIndividual practices, hospitals, and hospital systems should develop systems of care that deliver risk-appropriate care to women pre- and post-delivery.Managing PPH requires a comprehensive and interdisciplinary commitment from administrative and medical leaders.While there are prescriptive clinical interventions, highlighted in the practice plan, engaging expectant mothers and those supporting them is critical to the holistic improvement of an institution's obstetric safety including PPH.Women with risk factors for PPH should be identified and counseled as appropriate for their level of risk and gestational age.It is important that leaders ensure availability of resources such as personnel, equipment, blood products and trained personnel.Establishing PPH protocols, creation of PPH kits, and appropriate training and simulation drills reduces the risk of PPH. Practice PlanThe Council on Patient Safety in Women's Health Care developed comprehensive bundles and list of resources that apply to the prevention of harm from PPH and other maternal safety issues. The bundles are a roadmap for hospitals to use in the prevention of harm for these two pregnancy-related conditions.It is important to remember that approach to management of PPH depends on the etiology in a patient who has had a vaginal delivery or a cesarean section. Treatment of atony depends on the route of delivery. Coagulopathies are managed medically whilst trauma-related PPH is managed surgically.Technology PlanSuggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.Electronic Health Record (EHR)Web-based/EHR predictive algorithms that elicit specific data as but not limited to vital signs (BP, temp, HR, RR and SpO2), lab values, nurses notes and event reports.Close monitoring of hemodynamics such as heart rate and blood pressure.Ultrasound technology for assessment of retained products, retained placenta or abruption.MetricsSevere Maternal Morbidity among Hemorrhage CasesOutcome Measure FormulaNumerator: Among the denominator, all cases with any SMM codeDenominator: All mothers during their birth admission, excluding extopics and miscarriages, meeting one of the following criteria:Presence of an abruption, previa or antepartum hemorrhage diagnosis codePresence of transfusion procedure code without a sick cell crisis diagnosis codePresence of a postpartum hemorrhage diagnosis codeRate is typically displayed as: All cases w/ any SMM Code/All mothers meeting denominator criteriaMetric RecommendationsDirect Impact: All Pregnant PatientsLives Spared Harm:

Executive Summary ChecklistOpioid  induced  respiratory  depression  is  a  leading  cause  of  totally preventable  patient  death \cite{APSS4Cite2,APSS4Cite1,APSS4Cite3}. It  also  causes serious patient harm. Patients receiving opioids in the hospital have almost twice the incidence of cardiorespiratory arrest  compared  to  other  patients \cite{Overdyk_2016}. Establishing  an  effective  program  to  reduce  opioid-induced  respiratory depression will require full hospital administration support to complete the following actionable steps:Implement continuous electronic monitoring on all floors where patients are receiving opioid medications.Make continuous (not spot-check) monitoring of oxygenation the care standard. At a minimum, monitoring should include continuous measure through motion and low perfusion pulse oximetry (i.e. SET, until another technology is proven to be equivalent) with a central monitoring station with direct, immediate communication to the nurse on a mobile device.Monitor ventilation in patients receiving supplemental oxygen with either continuous capnography or acoustic respiration rate monitoring are technologies that can achieve this.Set appropriate respiratory rate (RR) alarms and apnea alarms to minimize alarm fatigue based on the patient population and individual risk of respiratory compromise. For example, RR between 6 and 30 breaths per minute, pulse rate (PR) between 40 and 100 for adults, PR between 70-120 for pediatric patients and a lower limit of 84% for SpO2)\cite{McGrath_2016}.Institute a rapid response notification system, which will alert staff if the patient is deteriorating. A plan for escalation of rapid response alarm to another staff member should also be in place.Hospital governance should commit to a plan that includes:Reviewing all reported patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the event. A review of all previous closed malpractice claims related to opioid induced respiratory depression should also be undertaken.Monitor and review all patients where naloxone was administered.Identifying and prioritizing common contributing factors from those serious preventable events.Identify and institute continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition, and ensure appropriate interventions are initiated in a timely manner.Providing the resources necessary to implement the action plan.Identifying a hospital “champion” who will be accountable for successful implementation, education and evaluation of the chosen plan.Developing an educational plan for all staff, patients and family members that shares common contributing factors leading to opioid induced respiratory depression.Implementation of a plan that eliminates current risks associated with opioids.Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.Develop a multimodal analgesic pain management program utilizing non-opioid adjuncts.Patients and caregivers should be educated to recognize potential side effects of opioids and sedatives, and notify caregivers immediately if they occur.The Performance GapComplications are inevitable and they are not always avoidable or the result of errors. However, when a patient dies because  of  a  complication  that  was  not  recognized  in  a  timely  manner  or  treated  appropriately,  that  death  is preventable  and  is  called  "Failure  to  Rescue."  Technology  and  knowledge  now  exist  to  anticipate  and  head  off  a serious  adverse  event  at  a  time  that  it  is  preventable  by  an  intervention.  The  combination  of  training,  technology, notification  and  computerized  data  analysis  will  allow  early  intervention  before  a  patient  reaches  a  critical  life threatening status.Monitors  now  exist  to  detect  respiratory  depression  as  well  as  sepsis,  hemodynamic  instability,  bleeding,  cardiacthreats,  and  even  the  risk  of  patient  fall  at  a  time  that an  intervention  can  be  made  in  time  to  avert  a  potential disaster.  The  development  of  early  warning  systems  (EWS)  has  been  well  studied  and  validated  in  Europe  and Australia \cite{Alam_2014,Ludikhuize_2012,Fullerton_2012,Smith_2013}. The technology to  support EWS is now robust and can be instituted very  easily into any institution. Even patients that have been discharged home can be monitored remotely.In-hospital  mortality  after  surgery  is  higher  than  anticipated  and  has  multiple  factors  that  can  be  systematically addressed \cite{Pearse_2012}. Healthcare  leadership  is  largely  unaware  of  significant  improvement  in  technology  that  can  detect  a patient  who  is  deteriorating  and  alert  the  caregivers  prior  to  an  adverse  event  occurring,  such  as  postoperative respiratory depression.After  the  Institute  of  Medicine  described  failure  to  rescue  as  a  key  issue  in  healthcare  quality  in  2001,  failure to rescue  was  identified  as  a  key  area  for  improvement  in patient  safety \cite{APSS4Cite11}. A  decade  later,  a  study  looked  at  patient safety  indicators  for  40  million  hospitalized  patients  and concluded  that  many  deaths  and  permanent  disabilities could  still  be  avoided  if  healthcare  systems  adopted  safe  practices  and  implemented  systems  that  facilitate  patient safety \cite{APSS4Cite12}. The  following  patient  safety  indicators  accounted  for  68%  of all  failure-to  rescue  patient  safety  events: death  among  surgical  inpatients  with  serious  treatable  complications,  pressure  ulcer,  postoperative  respiratory failure,  postoperative  sepsis.  The  study  further  identified  that  the  cost  associated  with  postoperative  respiratory failure alone in the U.S. Healthcare System is $2 billion.While opioid use is safe for most patients, opioid analgesics are associated with adverse effects and cause respiratory depression in significant number of post-surgical patients, who often receive them for pain management \cite{Vila_2005,1,APSS4Cite15,Jarzyna_2011,APSS4Cite17}. Of opioid-related adverse drug events – including deaths – that occurred in hospitals and were reported to The Joint Commission’s Sentinel Event database (2004-2011), 47% were wrong dosing medication errors, 29% were related to improper monitoring of the patient, and 11% were related to other factors including excessive dosing, medication interactions, and adverse drug reactions.Failure to Rescue postoperative respiratory depressions can be prevented through appropriate pain management and dosing  approaches,  surveillance  to  identify  patients  at  risk  for  Failure  to  Rescue,  notification  to  providers  of significant changes in patient condition, and automated decision support to ensure appropriate therapies are initiated in  a  timely  manner.  A  landmark  study  published  in  January  2010 by  Dartmouth-Hitchcock  Medical  Center demonstrated  that  clinicians  using  Masimo  SET®  measure  through  motion  and  low  perfusion  pulse  oximetry  and Patient SafetyNet™ Remote Monitoring and Clinician Notification System identified patient distress earlier, which decreased  rapid  response  team  activations  by  65%,  ICU  transfers by  48%,  and  reduce  ICU  days  by  135  days annually \cite{Taenzer_2010}.  A  follow  up  report  by  Dartmouth  in  2012 reported  that  since  December  2007  no  patients have  died  or had serious brain injuries as a result of respiratory depression from opioids. In addition, expanding monitoring to all general  and  thoracovascular  post-surgical  units  produced  similar  results  to  those  seen  in  the  original  orthopedic unit \cite{APSS4Cite19}. They  also  reported  savings  of  $58,459  saved  per patient  who  was  not  transferred  to  the  ICU  in the  original orthopedic unit ($76,044 vs. $17,585), equating to $1.48 million in annual opportunity cost savings in this one unit alone.In 2011,  the  Anesthesia  Patient  Safety  Foundation recommended  that all  patients receiving  parenteral narcotics  be monitored  continuously  and  a  notification  system  be  used  to  indicate  to  caregivers  when  alarming  conditions occur \cite{APSS4Cite20}. In  August  2012,  the  Joint  Commission  issued  a  sentinel  event alert,  urging  all  healthcare  systems  to introduce measures to improve safety for patient receiving opioids, including systematic protocols to assess pain and appropriate opioid dosing, as well as continuous monitoring of oxygenation and ventilation \cite{APSS4Cite21}. In 2014 the Center for Medicare  and  Medicaid  Services  (CMS)  clarified  the  surgical  services  CoP  requirement  for  hospitals  to  have adequate  provisions  for  immediate  postoperative  care,  to  emphasize  the  need  for  postoperative  monitoring  for patients receiving IV opioid medications, regardless of where they are in the hospital \cite{APSS4Cite22}.In spite of the calls to address failure to rescue for postoperative respiratory depression, pain assessment and opioid dosing  approaches  are  variable,  and  a  high  percentage  of  post-surgical  patients  on  parenteral  narcotics  are  not monitored  continuously.  The  lack  of  a  systematic  approach  to  prevent  failure  to  rescue  from  postoperative respiratory   depression   poses   significant   patient   safety, quality,   and   cost   of   care   implications.   Closing   the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans.Leadership PlanThe  plan  should  include  fundamentals  of  change  outlined  in  the National  Quality  Forum  safe  practices, including awareness, accountability, ability, and action \cite{APSS4Cite23}.Hospital  governance  and  senior  administrative  leadership  must  commit  to  become  aware  of  this  major performance gap in their own healthcare system.Hospital  governance,  senior administrative  leadership, and clinical/safety  leadership must  close  their  own performance gap by implementing a comprehensive approach to addressing the performance gap.A goal date should be set to implement the plan to address the gap with measurable quality indicators.“Some is not a number. Soon is not a time."\cite{APSS4Cite24}.Specific   budget   allocations   for   the   plan   should   be   evaluated   by   governance   boards   and   senior administrative leaders.Clinical/safety  leadership  should  endorse  the  plan  and  drive  implementation  across  all  providers  and systems.Practice PlanFormally  address  opportunities  to  improve  electronic  detection  of  deteriorating  patients  and  the  early notification of the caregivers. This includes the prevention of adverse events due to respiratory depression from pain medications.Implement systematic protocols  to assess pain management protocols and unify order sets where possible.Implement multi-modality pain strategies \cite{_NA__2012}.Implement  an  effective  system  to  accomplish  continuous  electronic  monitoring  and  notification  and escalation.Continuous  oxygenation  and/or  respiratory  monitoring  (not  spot  check  monitoring)  with  pulse oximetry  through  an  adhesive  sensor.    Pulse  Oximetry  with  measure  through  motion  and  low perfusion technology is preferred.Remote notification system that provides alarm notification to the care provider.A system of alarm escalation if the primary nurse does not respond in a timely manner.Set SpO2 alarms to reduce non-actionable alarmsDepending  on the  institution and  patient  populations  within  that institution, lower  alarm limits may be set to be conscious of alarm fatigue. Each institution should set limits to fit their specific patient population.Continuous  ventilation monitoring  (e.g.  capnography  or  respiratory  acoustic  rate  monitoring)  for reduced respiratory rate in patients on supplemental oxygen.Set respiration rate alarms to reduce non-actionable alarms (National Quality Forum 2010)Depending  on the  institution and  patient  populations  within  that institution, lower  alarm limits may be set to be conscious of alarm fatigue. Each institution should set limits to fit their specific patient population.Continuous electronic monitoring systems should integrate multiple physiologic parameters in the form of an index to identify clinically significant changes earlier and more reliability.Formalize transfer protocols from surgery and intensive care unit to postoperative general floor unit.Formalize workflows for patient admits and discharges from continuous monitoring.Rapid response teamIdentify the opportunities for implementation of rapid response teams and protocol for initiating a rapid response call for postoperative respiratory depression.(Alam 2014)Since family members are often highly sensitive to changes in a patient’s condition, it is advisable to  allow  families  to  ask  the  nurse  to  activate  the  rapid  response  system.  Families  should  be educated regarding this option \cite{Brady_2014}.Consider proactive rounding on high-risk patients by resource nurses with critical care training \cite{Hueckel_2006}.Technology PlanSuggested  technologies  are  limited  to  those  proven  to  show  benefit  or  are the  only  known  technologies  with  a particular capability. Other technology options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.Continuous pulse oximetryAdhesive  pulse  oximetry  sensor  connected  with  pulse  oximetry  technology  proven  to  measure through motion and  low  perfusion  to  avoid  false  alarms  and  detect  true  physiologic  events,  with added importance in care areas without minimal direct surveillance of patients (ie: Masimo SET® pulse  oximetry,  in  a  standalone  bedside  device  or  integrated  in  one  of  over  100  multi-parameter bedside monitors, until another technology is proven to be equivalent) \cite{Shah_2012}.Continuous respiratory rate monitoringAbility to accurately measure changes in respiratory rate and cessation of  breathing with optimal patient tolerance and staff ease of use in order to avoid false alarms, with added importance in care areas   without   minimal   direct   surveillance   of   patients   (e.g.   Masimo   rainbow®   Acoustic Monitoring \cite{Mimoz_2012},  EarlySense  Contact  Free  Monitoring  System,  or  sidestream  end-tidal  carbon dioxide monitoring such as Oridion®, Masimo® or Respironics®).Remote monitoring and notification systemRemote  monitoring  with  direct  clinician  alert  capability  compatible  with  recommended  pulse oximetry   technology   or   other   respiratory   rate   monitoring   technologies   (Masimo   Patient SafetyNet™,   EarlySense   Contact   Free   Monitoring   System   or   comparable   multi-parameter monitoring system).Direct  clinician  alert  through  dedicated  paging  systems  or existing  hospital  mobile  device notification system.NetworkMedical-grade  wireless  network  suitable  to  permit  reliable,  continuous  remote  monitoring  and documentation during ambulation and/or transport.Alternatively,  a  wired  network  can  be  used  which  allows  surveillance  of  patients  while they are in bed but not while they are ambulating.MetricsTopicAgency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) #11 Postoperative Respiratory Failure RateRate of patients with postoperative respiratory failure per 1,000 elective surgical discharges for patients 18 years and olderas defined by the Agency for Healthcare Quality and Research (AHRQ)Outcome Measure FormulaNumerator: Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with either:any secondary ICD-9-CM or ICD-10-CM diagnosis code for acute respiratory failure; orany-listed  ICD-9-CM  or  ICD-10-PCS  procedure  codes  for  a  mechanical  ventilation  for  96  consecutive hours or more that occurs zero or more days after the first major operating room procedure code (based on days from admission to procedure); orany-listed  ICD-9-CM  or  ICD-10-PCS  procedure  codes  for  a  mechanical  ventilation  for  less  than  96 consecutive  hours  (or  undetermined)  that  occurs  two  or  more  days  after  the  first  major  operating  room procedure code (based on days from admission to procedure); orany-listed ICD-9-CM or ICD-10-PCS procedure codes for a reintubation that occurs one or more days after the first major operating room procedure code (based on days from admission to procedure)Denominator: Elective surgical discharges, for patients ages 18 years and older, with any-listed ICD-9-CM or ICD-10-PCS procedure codes for an operating room procedure. Elective surgical discharges are defined by specific DRG or MS-DRG codes with admission type recorded as elective.Exclude cases:with a  principal ICD-9-CM  or  ICD-10-CM  diagnosis  code  (or  secondary  diagnosis  present  on  admission) for acute respiratory failure (see above)where the only operating room procedure is tracheostomywhere a procedure for tracheostomy occurs before the first operating room procedure†with any-listed ICD-9-CM or ICD-10-CM diagnosis codes for neuromuscular disorderwith  any-listed  ICD-9-CM  or  ICD-10-PCS  procedure  codes  for  laryngeal  or  pharyngeal,  nose,  mouth  or pharynx surgerywith  any-listed  ICD-9-CM  or  ICD-10-PCS  [if  appropriate]  procedure  codes  involving  the  face  and any-listed ICD-9-CM or ICD-10-CM diagnosis codes for craniofacial anomalieswith any-listed ICD-9-CM or ICD-10-PCS procedure codes for esophageal resectionwith any-listed ICD-9-CM or ICD-10-PCS procedure codes for lung cancerany-listed ICD-9-CM or ICD-10-CM diagnosis codes for degenerative neurological disorderMDC 4 (diseases/disorders of respiratory system)MDC 5 (diseases/disorders of circulatory system)MDC 14 (pregnancy, childbirth, and puerperium)with missing gender, age, quarter, year, or principal diagnosis† If day of procedure is not available in the input data file, the rate may be slightly lower than if the information was available.* Rate is typically displayed as Patients/1000 Elective surgical dischargesMetric RecommendationsDirect Impact: All elective surgical patientsLives Spared Harm: