Includes

• High-risk procedures, other than neurosurgical procedures, that include, but are not limited to, procedures involving the head and neck, spinal instrumentation procedures, and liver transplantation

• Low-risk procedures, including those related to lines placed for infusion of fluids in vascular space

Excludes

• Deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism

Includes

• Incorrect anesthetic gas

• Adverse reaction to anesthesia

• Under- or oversedation involving a medication or other substance (not including medical gas) (select both Anesthesia and Medication or other substance events)

• Under- or oversedation involving medical gas

• Malignant hyperthermia

• Incorrect site anesthesia

Excludes

• Contaminated anesthetic gas (select Contaminated, wrong or no gas given to a patient event)

• Anesthetic medication (select Medication or other substance event)

• Oversedation associated with medications after the patient has left the PACU (select Medication or other substance event)

• Problem with device used in the delivery of anesthesia (select Device or medical/surgical supply (including use error) event)

Includes

• Aspiration pneumonia or chemical pneumonia (select both Aspiration and Healthcare-associated infection events)

Excludes

Includes

• Hemolytic reaction

• Mislabeled blood

• Incorrect type

• Incorrect blood product

• Expired blood product

Excludes

Includes

• Burn caused by something other than a piece of equipment or medical supply (e.g. hot water, sunburn, smoking in patient/resident care environment)

Excludes

• Burn caused by a piece of equipment or medical supply (select Device or medical/surgical supply (including use error) event)

Includes

• Delay in treatment or intervention

• Delay in diagnosis

• Delay in recognizing changing condition

• Failure to rescue

Excludes

Includes

• Contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product

• Threat of disease that changes patient’s risk status for life requiring medical monitoring not needed before the event

• Administration of contaminated vaccine or medication (e.g., intramuscular antibiotic)

• Serious infection from contaminated drug or device used in surgery or an invasive procedure (e.g., a scalpel)

• Occurrences related to use of improperly cleaned or maintained device (e.g. unwashed medical equipment, unsterile instrument tray)

Excludes

• Contaminated gas (select Contaminated, wrong or no gas given to a patient event)

Includes

• Anesthetic or medical gases

Excludes

Includes

• Deep vein thrombosis with or without a pulmonary embolism that can be correlated to a surgical or other invasive procedure

Excludes

• Deep vein thrombosis with or without a pulmonary embolism whose formation cannot be correlated to a surgical or other invasive procedure

Includes

• Use error

• Scans read on incorrect monitor

• Non-functional/unavailable scanning equipment

• Patient misuse of equipment at home

• Latex gloves used for a procedure on a latex allergic patient

• Problem with device used in the delivery of anesthesia

Excludes

• Incorrect implant (select Surgical or other invasive procedure event)

• Incorrect graft tissue (select Surgical or other invasive procedure event)

• Unavailable equipment during a surgical procedure (select Surgical or other invasive procedure event)

• Using expired bone matrix admixture in a procedure (select Medication or other substance: Expired medication or other substance event)

Includes

• Patient death or injury associated with unintended electric shock during the course of care or treatment

Excludes

• Events involving patients during planned treatments such as electric countershock/elective cardioversion

• Patient death or injury associated with emergency defibrillation in ventricular fibrillation or with electroconvulsive therapies

• Injury to staff who are not involved in patient care

Includes

• Falls resulting in fractures, head injuries, intracranial hemorrhage

• Patient falls or drops from equipment (e.g., bed, lift)

• Patient would have fallen if they had not caught themselves or had not been assisted by another person

Excludes

• An anticipated loss of balance resulting from a supervised therapeutic intervention, during which the patient’s balance is being intentionally challenged during balance training

Includes

• Infections acquired in the acute care setting that result in readmission, increased length of stay, or cause/contribute to patient death

• Primary blood stream infections

• Central line associated blood stream infections (CLABSI)

• Pneumonia

• Ventilator-associated pneumonia (VAP)

• Surgical site infection (SSI)

Excludes

• Infections present or incubating on admission treated and eliminated prior to discharge

• Infection resulting from contaminated device, drug or biologic (select Contaminated device, drug or biologic event)

Includes

• Biological specimens that cannot be replaced associated with mislabeled pathology, lab error resulting in transfer of patient to another facility, omitted tests, or incorrect results

Excludes

• Mislabeled blood (select Blood or blood product event)

• Lost specimen that is not noticed until later (select Other event)

Includes

• Adverse reaction not due to allergy or known contraindication

• Allergic reaction due to unknown allergy

• Anesthetic medication

• Contrast media or other diagnostic substances

• Drug interaction

• Expired medication or other substance

• Hypoglycemia

• Incorrect dosage form

• Incorrect dose

• Incorrect medication or substance

• Incorrect or incomplete labeling

• Incorrect patient

• Incorrect preparation

• Incorrect rate

• Incorrect route

• Incorrect time

• Incorrect strength or concentration

• Medication or other substance discontinued

• Medication or other substance is contraindicated (includes documented allergies and sensitivities)

• Medication or other substance omitted

• Oversedation involving a medication or other substance (not including medical gas) (select both Anesthesia and Medication or other substance events)

Excludes

• Reasonable differences in clinical judgment on drug selection and dose

• Adverse reaction to anesthesia (select Anesthesia event)

• Blood product (select Blood or blood product event)

• Oversedation involving medical gas (select Anesthesia event)

Includes

• Strangulation associated with the use of a restraint or bed rail

• Entrapment

Excludes

Includes

• Dehiscence, flap or would failure or disruption, or graft failure

• Endoscopies

• Iatrogenic pneumothorax

• Incorrect implant or graft tissue

• Injection into joints

• Intraoperative or immediate post-operative death

• Laceration

• Lens implants

• Lesion removal

• Nick

• Perforation

• Postoperative bleeding requiring return to operating room

• Postoperative death directly attributable to surgical procedure

• Postoperative nausea requiring hospital admission

• Puncture

• Unanticipated blood transfusion

• Unintended blockage, obstruction, or ligation

• Unplanned admission to the hospital within 48 hours of discharge from an ambulatory surgery center

• Unplanned emergency department admission within 48 hours of discharge from an ambulatory surgery center

• Unplanned removal of an organ

Excludes

Includes

• Medical or surgical items intentionally placed by provider(s) that are unintentionally left in place

• Objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the risk of retention (such as some needles, broken screws)

Excludes

• Objects intentionally implanted as part of a planned intervention and objects present prior to surgery that were intentionally retained

• Objects present prior to surgery or other invasive procedure that are intentionally left in place

• Objects intentionally implanted as part of a planned intervention

Includes

• Any unanticipated, usually preventable event that results in serious physical injury, even if the harm is temporary

• Only events that are not related to the natural course of the patient’s illness or underlying condition

• Injuries not related to another event

• Events related to poor discharge planning or inadequate patient assessment

• Premature pronouncement of death

• Transfer/transport related events

• Events related to spinal manipulative therapy

Excludes

• Events related to the natural course of the patient’s illness or underlying condition

• Injuries related to another event