Includes

• High-risk procedures, other than neurosurgical procedures, that include, but are not limited to, procedures involving the head and neck, vaginal delivery and caesarean section, 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/surgical supply (e.g. hot water, sunburn, smoking in patient care environment)

Excludes

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

• Burn caused by MRI (select Radiologic event)

Includes

• Delay in treatment or intervention

• Delay in diagnosis

• Delay in recognizing changing condition

• Failure to rescue

Excludes

• Delay in notifying patient or provider of lab or radiology reports (select Failure to follow up or communicate laboratory, pathology, or radiology test results event)

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

• Use error

• Scans read on wrong 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

• Newborns

• Minors

• Adults with cognitive impairments (e.g., Alzheimer’s and dementia)

Excludes

• Events involving competent adults with decision-making capacity who leave against medical advice or voluntarily leave without being seen

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

• Events that occur after the individual presents him/herself for care in a healthcare setting

Excludes

• Events involving competent adults with decision-making capacity who leave against medical advice or voluntarily leave without being seen

• Death or serious injury that occurs (after the patient is located) due to circumstances unrelated to the elopement

Includes

• Delay in notifying patient or provider of lab or radiology reports

• Misreporting critical test results

• Failure to identify and treat hyperbilirubinemia in neonate (hyperbilirubinemia is defined as bilirubin levels >30 mg/dl in neonates)

• Mislabeled pathology

• Lab error resulting in transfer of patient to another facility

• Omitted tests

• Incorrect results

Excludes

• Biological specimens that cannot be replaced associated with mislabeled pathology (select Irretrievable loss of an irreplaceable biologic specimen event)

Includes

• Falls resulting in fractures, head injuries, intracranial hemorrhage

• Newborn or infant drops

• 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

• Falls associated with suicide or attempted suicide (select Suicide or attempted suicide event)

• 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)

• Sepsis

• Surgical site infection (SSI)

• Urinary tract infection (UTI)

• Catheter-associated urinary tract infection (CAUTI)

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

• Miscommunicated or lost laboratory, pathology, or radiology test results (select Failure to follow up or communicate laboratory, pathology, or radiology test results event)

• Biological specimens that can be replaced associated with mislabeled pathology, lab error resulting in transfer of patient to another facility, omitted tests, or incorrect results (select Failure to follow up or communicate laboratory, pathology, or radiology test results event)

• Mislabeled blood (select Blood or blood product event)

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

Includes

• Maternal death

• Third or fourth degree perineal lacerations or tears

• Uterine rupture

Excludes

• Deaths from pulmonary or amniotic fluid embolism (select Other event)

• Acute fatty liver of pregnancy (select Other event)

• Cardiomyopathy (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

• Stillbirth

• Shoulder dystocia

• Encephalopathy

• Neonatal resuscitation

• Newborn death

• Fetal demise

Excludes

• Events that occur outside of the perinatal period (which extends from the 20th week of gestation through 4 weeks (28 days) postpartum)

Includes

• Stage 3 or 4 pressure injuries, or pressure injuries present on admission that progressed during the patient’s stay (see exclusions)

• Suspected deep tissue injuries

• Unstageable pressure injuries

• Those that were not present on admission and occurred prior to patient discharge (i.e., newly-developed)

Excludes

• Progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission

• Pressure injuries that develop in areas where deep tissue injury is documented as present on admission/presentation

Includes

• The NQF Serious Reportable Event “death or serious injury of a patient associated with the introduction of a metallic object into the MRI area”

• MRI too small for patient on which it was used

• Patient overdosed by poorly calibrated CT or similar

• Delivery of fluoroscopy or radiotherapy to the wrong region of the body

• Burns resulting from MRI

Excludes

• Scans read on wrong monitor (select Device or medical/surgical supply (including use error) event)

• Non-functional/unavailable scanning equipment (select Device or medical/surgical supply (including use error) event)

Includes

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

• Entrapment

Excludes

• Suicide (select Suicide or attempted suicide event)

Includes

• Events that result from patient actions after admission to a healthcare facility

Excludes

• Deaths resulting from self-inflicted injuries that were the reason for admission/presentation to the healthcare facility

Includes

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

• Endoscopies

• Iatrogenic pneumothorax

• Incorrect implant or graft tissue

• Injection into joints

• Laceration

• Lens implants

• Lesion removal

• Nick

• Perforation

• Postop bleeding requiring return to operating room

• Puncture

• Unintended blockage, obstruction, or ligation

• 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

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

• Thromboembolism

• 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