Description
Determination of the event type that is being reported.
This page defines hospital event types.
Click here for ambulatory surgery center event types.
Click here for nursing facility event types.
Click here for pharmacy event types.
On-Screen Instructions
Check only one. If the event consists of multiple event types, select only the precipitating event that best describes the situation. In rare cases, reports may involve two distinct adverse events in which case multiple adverse events may be selected.
Field Type
Checkbox (multi-select)
Responses
Air Embolism
Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare facility.
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
Malignant hyperthermia
Incorrect site anesthesia
Excludes
Contaminated anesthetic gas (submit as “Contaminated, wrong or no gas given to a patient”)
Anesthetic medication (submit as “medication or other substance”)
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)”)
Event Specific Questions Triggered by Selecting This Event Type |
Aspiration
Patient death or serious injury associated with an aspiration.
Includes
Aspiration pneumonia (submit as both “Aspiration” and “Healthcare-associated infection” events)
Blood or blood product (including hemolytic reactions)
Patient death or serious injury associated with unsafe administration of blood products.
Includes
Hemolytic reaction
Mislabeled blood
Incorrect type
Incorrect blood product
Expired blood product
Event Specific Questions Triggered by Selecting This Event Type |
Burn (unrelated to the use or misuse of a device or medical/surgical supply)
Patient/resident death or serious physical injury associated with a second or third degree burn incurred from any source other than the use or misuse of a device or medical supply while being cared for in a healthcare facility.
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))
Burn caused by MRI (submit as Radiologic)
Care delay (including delay in treatment, diagnosis)
Patient death or serious injury related to a delay in care, diagnosis, or treatment.
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”)
Contaminated drugs, devices or biologics
Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting.
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”)
Event Specific Questions Triggered by Selecting This Event Type |
Contaminated, wrong or no gas given to a patient
“Contaminated, wrong or no gas given to a patient” is considered a serious event type regardless of patient harm.
Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances.
Includes
Anesthetic or medical gases
Device or medical/surgical supply (including use error)
Patient death or serious injury associated with the use or function of a device or medical/surgical supply in patient care, in which the device is used or functions other than as intended.
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”)
Event Specific Questions Triggered by Selecting This Event Type |
Additional Support |
Discharge or release of a patient of any age, who is unable to make decisions, to an unauthorized person
Discharge or release of a patient of any age, who is unable to make decisions, to an unauthorized person.
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
Electric shock
Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting.
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
Elopement
Patient death or serious injury associated with patient elopement (disappearance).
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
Failure to follow up or communicate laboratory, pathology, or radiology test results
Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.
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 (submit as “irretrievable loss of an irreplaceable biologic specimen”)
Fall
Patient death or serious injury associated with a fall while being cared for in a healthcare setting. “Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
Includes
Falls resulting in fractures, head injuries, intracranial hemorrhage
Newborn or infant drops
Patient falls or drops from equipment (e.g., bed, lift)
Excludes
Falls associated with suicide or attempted suicide (submit as Suicide or attempted suicide)
Event Specific Questions Triggered by Selecting This Event Type |
Additional Support |
Healthcare-associated infection (HAI) (including surgical site infections up to 30 days postoperatively)
Patient death or serious injury associated with an infection acquired while being cared for in a healthcare setting.
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 (submit as “Contaminated device, drug or biologic”)
Event Specific Questions Triggered by Selecting This Event Type |
Irretrievable loss of irreplaceable biological specimen
Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen.
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 (submit as “failure to follow up or communicate laboratory, pathology, or radiology test results”)
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 (submit as “failure to follow up or communicate laboratory, pathology, or radiology test results”)
Mislabeled blood (submit as “Blood or blood product”)
Lost specimen that is not noticed until later (submit as “Other”)
Maternal
Death or serious injury of a woman associated with labor or delivery while being cared for in a healthcare facility.
Includes
maternal death; third or fourth degree perineal lacerations or tears; uterine rupture
Excludes
deaths from pulmonary or amniotic fluid embolism; acute fatty liver of pregnancy; cardiomyopathy
Event Specific Questions Triggered by Selecting This Event Type Filter by labelThere are no items with the selected labels at this time. |
Medication or other substance
Patient death or serious injury associated with a medication or other substance.
Includes
Adverse reaction
Allergic reaction
Anesthetic medication
Contraindication
Contrast media or other diagnostic substances
Drug interaction
Expired medication or 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
Excludes
Reasonable differences in clinical judgment on drug selection and dose
Adverse reaction to anesthesia (submit as “Anesthesia”)
Blood product (submit as “Blood or blood product”)
Event Specific Questions Triggered by Selecting This Event Type |
Additional Support Filter by labelThere are no items with the selected labels at this time. |
Event type | Definition |
|---|---|
Medication or other substance | Patient death or serious injury associated with a medication or other substance. INCLUDES: hypoglycemia; incorrect medication or substance; incorrect dose; incorrect patient; incorrect time; incorrect rate; incorrect preparation; incorrect route of administration, incorrect dosage form; incorrect strength; expired medication or substance; incorrect or incomplete labeling; contraindication; omission/discontinuation; adverse reaction, allergic reaction; drug interaction; anesthetic medication; contrast media or other diagnostic substances; oversedation EXCLUDES: reasonable differences in clinical judgment on drug selection and dose; adverse reaction to anesthesia (submit as “anesthesia”); blood product (submit as “blood or blood product”) Additional Support |
Perinatal | Death or serious injury of a fetus or neonate during the perinatal period associated with labor or delivery while being cared for in a healthcare facility. 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) |
Pressure injury (H) | Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting. INCLUDES: Stage 3 or 4 pressure ulcers, or pressure ulcers present on admission that progressed during the patient’s stay (see exception below); suspected deep tissue injuries; unstageable pressure ulcers; 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 ulcers that develop in areas where deep tissue injury is documented as present on admission/presentation |
Radiologic | Patient death or serious injury associated with radiologic treatment. 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 (submit as “device or medical/surgical supply”); non-functional/unavailable scanning equipment (submit as “device or medical/surgical supply”) |
Restraint or bed rail related | Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare facility. INCLUDES: strangulation; entrapment EXCLUDES: suicide (submit as “suicide or attempted suicide”) |
Suicide or attempted suicide | Patient suicide or attempted suicide resulting in serious physical injury, while being cared for in a healthcare facility. 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 |
Surgical or other invasive procedure | Patient death or serious injury associated with a surgery or invasive procedure and any injury resulting from an incorrect patient, incorrect site surgery or invasive procedure, or incorrect procedure event. INCLUDES
Related Content |
Unintended retained foreign object | Unintended retention of a foreign object in a patient after surgery or other invasive procedure. 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 |
Other | Patient death or serious injury related to an event not otherwise included in the above categories. 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 |
Additional Guidance
Additional Support
History
Start Date | Spring 2012 |
|---|---|
End Date | n/a |
Change History | May 2013: HIT removed as an event type. Additional specification added to Surgical or other invasive procedure and HAI. HIT was too hard to define as an event type, so it was moved into “Additional event questions” to be asked of all events. Many Surgical or other invasive procedure events were being submitted as “Other” because participants were looking for the old categories. Clarified what was required for HAI reports, according to Appendix A of our Administrative Rules. 2014: Prompt updated and shortened. January 2015: updated “Unintended retained foreign object” to “Unintended retained foreign object (includes retained surgical items).” April 2016: Fixed omitted word “communication” in answer option 13 (“Failure to follow up or communicate laboratory, pathology, or radiology test results”). |