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

• Malignant hyperthermia

• Incorrect site anesthesia

Excludes

• Contaminated anesthetic gas (submit as “Contaminated, wrong or no gas given to a patient”)

• Oversedation associated with medications after the patient has left the PACU (submit as “Medication or other substance”)

• Problem with device used in the delivery of anesthesia (submit as “Device or medical/surgical supply (including use error)”)

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

• 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 (submit as Device or medical/surgical supply (including use error))Aspiration pneumonia or chemical pneumonia (select both Aspiration and Healthcare-associated infection events)

Excludes

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 (submit as “Failure to follow up or communicate laboratory, pathology, or radiology test results”) 🚨 Hemolytic reaction

• Mislabeled blood

• Incorrect type

• Incorrect blood product

• Expired blood product

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 (submit as “Contaminated, wrong or no gas given to a patient”)

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

• 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 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 (submit as “Surgical or other invasive procedure” event)

• Incorrect graft tissue (submit as “Surgical or other invasive procedure” event)

• Unavailable equipment during a surgical procedure (submit as “Surgical or other invasive procedure” event)

• Using expired bone matrix admixture in a procedure (submit as “Expired medication or substance”)

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

• 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 hemorrhageNewborn or infant drops 🚨

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

Excludes

• Falls associated with suicide or attempted suicide 🚨 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 (submit as “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 (submit as “failure to follow up or communicate laboratory, pathology, or radiology test results”) 🚨

Excludes

• Mislabeled blood (submit as “select Blood or blood product” event)

• Lost specimen that is not noticed until later (submit as “select Other” event)

Includes

• Adverse reaction Allergic reactionnot due to allergy or known contraindication

• Allergic reaction due to unknown allergy

• Anesthetic medication Contraindication

• 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 of administration

• Incorrect time

• Incorrect strength or concentration

• Omission or discontinuation

• Oversedation

• 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 (submit as “select Anesthesia” event)

• Blood product (submit as “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

• Immediate postoperative bleeding requiring surgical treatment (before discharge)

• 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 organWrong graft tissueorgan

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