Includes

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

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 supply (including use error) event)

Includes

• Delay in treatment or intervention

• Delay in diagnosis

• Delay in recognizing changing condition

• Failure to rescue

Excludes

Includes

• Choking resulting from food not indicated for dietary needs (e.g., receiving a regular diet when assessed for a therapeutic diet) or medication in the incorrect form or route based on choking hazard/dietary needs

• Choking resulting from inappropriate eating assistance

• Choking resulting from patient/resident attempting to ingest an item not indicated for consumption

Excludes

• Events associated with a patient/resident’s personal choice to receive a diet not indicated for their dietary needs and when associated risks have been communicated and documented

Includes

• The patient/resident had clinical conditions that are the primary risk factors for a decreased range of motion (e.g., immobilization, deformities arising out of neurological deficits, and pain, spasms, and immobility associated with arthritis or late state Alzheimer’s disease) but development was avoidable (i.e., facility did not provide adequate assessment, appropriate care planning, and preventive care)

Excludes

• A contracture that is unavoidable due to limb or digit immobilization resulting from injury or surgical procedures (e.g., surgical adhesions)

• The patient/resident had clinical conditions that are the primary risk factors for a decreased range of motion (e.g., immobilization, deformities arising out of neurological deficits, and pain, spasms, and immobility associated with arthritis or late state Alzheimer’s disease) but development was unavoidable (i.e., facility provided adequate assessment, appropriate care planning, and preventive care)

Includes

• Use error

• Non-functional/unavailable equipment

• Patient/resident misuse of equipment at home

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

Excludes

Includes

• Diabetic coma related to hypoglycemia or hyperglycemia

Excludes

Includes

• 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

• Events that occur after the individual presents 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/resident is located) due to circumstances unrelated to the elopement

Includes

• Falls resulting in fractures, head injuries, intracranial hemorrhage

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

• Patient/resident 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/resident’s balance is being intentionally challenged during balance training

Includes

• Infections associated with being cared for in a facility that result in increased length of stay or cause/contribute to patient/resident death, for example:

  • Eye, ear, nose, throat, and mouth infections; gastrointestinal system infections

  • Lower respiratory tract infections (including pneumonia and ventilator-associated pneumonia (VAP))

• Primary blood stream infections

• Central line associated blood stream infections (CLABSI)

• Pneumonia

• Ventilator-associated pneumonia (VAP)

• Sepsis

• Skin or soft tissue infections

• Urinary tract infection (UTI)

• Catheter-associated urinary tract infection (CAUTI))

Excludes

• Infections present or incubating on admission that are assessed and treated appropriately

Includes

• IV lines inserted in another facility if the event occurred as a result of care at your facility

• IV lines inserted and care for in your facility

Excludes

Includes

• Adverse reaction not due to allergy or known contraindication

• Allergic reaction due to unknown allergy

• Drug interaction

• Expired medication or substance

• Hypoglycemia

• Incorrect dosage form

• Incorrect dose

• Incorrect medication or substance

• Incorrect or incomplete labeling

• Incorrect patient/resident

• Incorrect preparation

• Incorrect rate

• Incorrect route

• Incorrect strength or concentration

• Incorrect time

• Medication or other substance discontinued

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

• Medication or other substance omitted

• Oversedation

Excludes

• Reasonable differences in clinical judgment on drug selection and dose

Includes

• Stage 3 or 4 pressure injuries, or pressure injuries present on admission that failed to show evidence of stabilization or healing within 2-4 weeks; suspected deep tissue injuries

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

• Development of a pressure injury in a patient/resident who’s clinical condition demonstrates that it was unavoidable

• Failure of a pressure injury that was present on admission to show evidence or progress towards stabilization or healing within 2-4 weeks when the complexity of the patients/resident’s condition is such that it may limit responsiveness to treatment or tolerance for certain treatment modalities.

Includes

• Assisted transfers

• Patient/resident self-transfers

• Transfers using a lift

Excludes

• Patient/resident transfers from one facility to another (e.g., from the nursing home to the hospital) (select Other event)

Includes

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

• Entrapment

Excludes

• Suicide (select Suicide or attempted suicide)

Includes

• Unintentional strangulation associated with window blind cords or other object within a facility that are not restraints or bed rails

Excludes

• Strangulation associated with the use of a restraint or bed rail (select Restraint or bed rail related)

• Suicide (select Suicide or attempted suicide)

Includes

• Events that result from patient/resident actions while receiving care or within 7 days of discharge from a healthcare setting

Excludes

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

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/resident’s illness or underlying condition

• Events related to poor discharge planning or inadequate patient/resident assessment

• Events related to spinal manipulative therapy

• Injuries not related to another event

• Poisoning

• Premature pronouncement of death

• Thromboembolism

• Events related to the transfer or transport of a patient/resident from one facility to another

Excludes

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

• Injuries related to another event