Annual National Patient Safety Goals
In our commitment to providing the highest quality care to our patients, Lighthouse Surgery Center utilizes the Annual Quality Collaboration Report for national benchmarking purposes. This data is submitted by participating ambulatory surgery centers and made available by the ASC Quality Collaboration. For each category you will see the quality measure, the national average rate per 1,000 patients, and the rate of incidence at Lighthouse Surgery Center per 1,000 patients.
Patient Fall in the ASC
Falls are an important issue for patients having outpatient procedures or surgery because virtually all patients receive sedatives, anesthetics and/or pain medications as a routine part of their care. The use of these medications increases the likelihood of a fall. The frequency of ASC admissions experiencing a fall while in the confines of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Falls are an important issue for patients having outpatient procedures or surgery because virtually all patients receive sedatives, anesthetics and/or pain medications as a routine part of their care. The use of these medications increases the likelihood of a fall. The frequency of ASC admissions experiencing a fall while in the confines of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Patient Falls |
Average 2020-2023 |
National Patient Fall Rate per 1000 Admissions |
0.01% |
Lighthouse Patient Fall Rate per 1000 ASC Admissions |
0.009% |
Patient Burns
Burns are an important issue for patients having outpatient procedures or surgery because the equipment and supplies routinely used in providing these types of services can increase the risk that a patient will experience an unintended burn. The frequency of ASC admissions experiencing a burn, regardless of severity, while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Burns are an important issue for patients having outpatient procedures or surgery because the equipment and supplies routinely used in providing these types of services can increase the risk that a patient will experience an unintended burn. The frequency of ASC admissions experiencing a burn, regardless of severity, while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Patient Burns |
Average 2020-2023 |
National Patient Burn Rate per 1000 Admissions |
0.002% |
Lighthouse Patient Burn Rate per 1000 Admissions |
0.0% |
Hospital Transfer/Admission
ASCs provide surgical services to patients not requiring hospitalization. Therefore, ASCs screen patients referred to their facilities to ensure they can be safely cared for as an outpatient. The frequency of ASC admissions experiencing a transfer or admission to a hospital upon discharge from participating ASCs is shown below as a rate per 1000 admissions. Not all conditions requiring a hospital transfer or admission result from the care the patient received in the ASC, nor can all medical conditions requiring a hospital transfer or admission be anticipated in advance. Therefore, some level of hospital transfer or admission is expected.
ASCs provide surgical services to patients not requiring hospitalization. Therefore, ASCs screen patients referred to their facilities to ensure they can be safely cared for as an outpatient. The frequency of ASC admissions experiencing a transfer or admission to a hospital upon discharge from participating ASCs is shown below as a rate per 1000 admissions. Not all conditions requiring a hospital transfer or admission result from the care the patient received in the ASC, nor can all medical conditions requiring a hospital transfer or admission be anticipated in advance. Therefore, some level of hospital transfer or admission is expected.
Patient Transfers |
2020 |
2021 |
2022 |
2023 |
National Hospital Transfer/Admission Rate per 1000 ASC Admissions |
0.08% |
0.08% |
0.08% |
0.08% |
Lighthouse Transfer/Admission Rate per 1000 Admissions |
0.10% |
0.14% |
0.08% |
0.05% |
Wrong Site, Side, Patient, Procedure, Implant
Wrong site, wrong side, wrong patient, wrong procedure and wrong implant events are a concern for patients having outpatient procedures or surgery. There are steps that can be taken to help prevent errors such as surgery performed on the wrong part of the body or the wrong side of the body. The frequency of ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Wrong site, wrong side, wrong patient, wrong procedure and wrong implant events are a concern for patients having outpatient procedures or surgery. There are steps that can be taken to help prevent errors such as surgery performed on the wrong part of the body or the wrong side of the body. The frequency of ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.
Wrong SSPPI |
Average 2020-2023 |
National Rate of Wrong Site, Side, Patient, Procedure, Implant per 1000 Admissions |
.003% |
Lighthouse Rate of Wrong Site, Side, Patient, Procedure, Implants per 1000 ASC Admissions |
0.0% |
Normothermia
Maintaining body temperature within a normal range (normothermia) is important in patients who have general, spinal or epidural anesthesia lasting 60 minutes or more at the time of surgery. Normothermia helps reduce the risk of surgical complications, including the risk of developing an infection at the surgical site. The percentage of eligible ASC patients that are normothermic within 15 minutes of arrival into the Post Anesthesia Care Unit (PACU) is displayed below. Higher percentages are better.
Maintaining body temperature within a normal range (normothermia) is important in patients who have general, spinal or epidural anesthesia lasting 60 minutes or more at the time of surgery. Normothermia helps reduce the risk of surgical complications, including the risk of developing an infection at the surgical site. The percentage of eligible ASC patients that are normothermic within 15 minutes of arrival into the Post Anesthesia Care Unit (PACU) is displayed below. Higher percentages are better.
Normothermia |
2020 |
2021 |
2022 |
2023 |
National Normothermia Rate |
98.7% |
98.9% |
99.1% |
98.9% |
Our Normothermia Rate |
N/A |
N/A |
97% |
97% |
Emergency Department Visit Within 24 Hours of Discharge
Patients undergoing ambulatory surgery are expected to recover at home following discharge. An emergency department visit within one day of discharge is an unexpected event. Not all conditions requiring an emergency visit result from the care the patient received in the ASC, nor can all medical conditions requiring an emergency department visit following discharge be anticipated in advance. Therefore, some level of emergency department visits following discharge is to be expected. The frequency of ASC admissions experiencing an emergency department visit within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
Patients undergoing ambulatory surgery are expected to recover at home following discharge. An emergency department visit within one day of discharge is an unexpected event. Not all conditions requiring an emergency visit result from the care the patient received in the ASC, nor can all medical conditions requiring an emergency department visit following discharge be anticipated in advance. Therefore, some level of emergency department visits following discharge is to be expected. The frequency of ASC admissions experiencing an emergency department visit within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
ED Visit within 24H |
2020 |
2021 |
2022 |
2023 |
National ED Visit Rate per 1000 ASC Admissions |
0.07% |
0.07% |
0.06% |
0.06% |
Our ED Visit Rate per 1000 ASC Admissions |
0.00 |
0.06% |
0.02% |
0.06% |
Unplanned Hospital Admission Within 24 Hours of Discharge
Patients undergoing ambulatory surgery are expected to recover at home following discharge. An unplanned hospital admission within one day of discharge is an unexpected event. Not all conditions requiring a hospital admission result from care the patient received in the ASC, nor can all medical conditions requiring an unplanned hospital admission be anticipated in advance. Therefore, some level of unplanned hospital admissions is to be expected. The frequency of ASC admissions experiencing an unplanned hospital admission within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
Patients undergoing ambulatory surgery are expected to recover at home following discharge. An unplanned hospital admission within one day of discharge is an unexpected event. Not all conditions requiring a hospital admission result from care the patient received in the ASC, nor can all medical conditions requiring an unplanned hospital admission be anticipated in advance. Therefore, some level of unplanned hospital admissions is to be expected. The frequency of ASC admissions experiencing an unplanned hospital admission within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
Unplanned Admit within 24H |
2020 |
2021 |
2022 |
2023 |
National Hosp. Visit Rate per 1000 Admissions |
0.03% |
0.02% |
0.02% |
0.02% |
Our Hosp. Visit Rate per 1000 Admissions |
0.0% |
0.0% |
0.01% |
0.05% |
Surgical Site Infections
Even with the many precautions and protocols in place, any surgery causing a break in the skin can lead to an infection. A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can be superficial infections involving the skin only, deep infections occurring beneath the skin in the muscle and tissue areas, or organ/space infections which would include organs or the spaces between them. If you have surgery, the chances of developing a surgical site infection are between 1% and 3%. The frequency of ASC admissions experiencing a surgical site infection is shown below as a rate per 1000 admissions. Lower rates are better. (*This data is reported annually by the NHSN, it reflects only the comparable surgical procedures performed at acute care hospitals that are also performed at Lighthouse Surgery Center. 2023 data not available as of 5/1/2024)
Even with the many precautions and protocols in place, any surgery causing a break in the skin can lead to an infection. A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can be superficial infections involving the skin only, deep infections occurring beneath the skin in the muscle and tissue areas, or organ/space infections which would include organs or the spaces between them. If you have surgery, the chances of developing a surgical site infection are between 1% and 3%. The frequency of ASC admissions experiencing a surgical site infection is shown below as a rate per 1000 admissions. Lower rates are better. (*This data is reported annually by the NHSN, it reflects only the comparable surgical procedures performed at acute care hospitals that are also performed at Lighthouse Surgery Center. 2023 data not available as of 5/1/2024)
Surgical Site Infections |
2020 |
2021 |
2022 |
2023 |
National SSI Rate per 1000 Hospital Admissions |
0.54% |
0.55% |
0.60% |
* |
Our SSI Rate per 1000 ASC Admissions |
0.27% |
0.19% |
0.12% |
0.15% |
