Description
Determination of the event type that is being reported.
On-Screen Instructions
Select 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 (multiselect)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, 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)
Event-Type Specific Questions |
Aspiration
Patient death or serious injury associated with an aspiration.
Includes
Aspiration pneumonia or chemical pneumonia (select both Aspiration and Healthcare-associated infection events)
Excludes
No additional information provided.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
Excludes
No additional information provided.Event-Type Specific Questions |
Burn (unrelated to the use or misuse of a device or medical/surgical supply)
Patient 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 (select Device or medical/surgical supply (including use error) event)
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
No additional information provided.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 (select Contaminated, wrong or no gas given to a patient event)
Event-Type Specific Questions |
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
Excludes
No additional information provided.Deep vein thrombosis with or without pulmonary embolism
"Deep vein thrombosis with or without pulmonary embolism" is considered a serious event type regardless of patient harm.
Patient death or serious injury associated with a surgical or other invasive procedure that resulted in the formation of a deep vein thrombosis
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
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 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)
Event-Type Specific Questions |
Additional Support |
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
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., being pushed to the ground). An episode where a patient 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 patient is found on the floor, a fall is considered to have occurred.
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
Event-Type Specific Questions |
Additional Support |
Healthcare-associated infection (HAI) (including surgical site infections up to 30 days postoperatively)
"Surgical site infection up to 30 days postoperatively" is considered a serious event type regardless of patient harm.
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)
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)
Event-Type Specific Questions |
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
Mislabeled blood (select Blood or blood product event)
Lost specimen that is not noticed until later (select Other event)
Medication or other substance
Patient death or serious injury associated with a medication or other substance.
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)
Event-Type Specific Questions |
Restraint or bedrail related
Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare facility.
Includes
Strangulation associated with the use of a restraint or bed rail
Entrapment
Excludes
No additional information provided.Surgical or other invasive procedure (including unplanned admission to hospital, unplanned emergency department visit, incorrect site, incorrect patient, incorrect procedure, etc.)
"Unplanned admission to hospital," "unplanned emergency department visit," "incorrect site," "incorrect patient," and "incorrect procedure" are considered serious event types regardless of patient harm.
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
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
No additional information provided.Event-Type Specific Questions |
Additional Support |
Unintended retained foreign object (includes retained surgical items)
"Unintended retained foreign object (includes retained surgical items)" is considered a serious event type regardless of patient harm.
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
Objects intentionally implanted as part of a planned intervention
Event-Type Specific Questions |
Other event (please describe)
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
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
Guide for Use
If “Other” is selected, a text box for a description will also appear.Additional Support
Sometimes an event seems to fit two or more event types. When completing a PSRP report, how do I determine the correct event(s)?
Even though an event may seem to fit more than one type, the Oregon Patient Safety Commission (OPSC) encourages participants to identify the primary event from which subsequent events resulted when completing a Patient Safety Reporting Program (PSRP) report. Identifying the primary event helps focus an investigation and determination of the root cause and increases the likelihood that action plans resulting from the investigation will truly prevent recurrence (see Scenario 1, below).
Not every PSRP report has a primary event; sometimes there are multiple, independent events that affect the same patient at the same time (see Scenario 2, below). Some are obviously related, but have different causes (e.g., the wrong medication is administered, resulting in respiratory distress, and the resuscitation equipment breaks). Other events may be more difficult to identify. For example, medication events can have multiple opportunities for a “good catch” before they reach the patient, making them seem like multiple events in retrospect (see Scenario 3, below). When determining the primary event, investigators should ask, “If one of these events had been prevented, would the others have still occurred?”
Scenario | Primary Event Type | Discussion | |
|---|---|---|---|
| 1 | A patient is misidentified, taken to the operating room, and the wrong procedure is performed. | Incorrect patient | Incorrect patient should be reported as the primary event. The incorrect procedure was a result of the patient misidentification. |
| 2 | In mixing three medications for topical administration, the first medication is added correctly, only half of the desired dose of the second medication is added, the third medication is omitted, and the container is left unlabeled. | This is three medication events:
| This is three medication events: (1) the patient received an incorrect dose of one medication, (2) the patient received no dose of another medication, and (3) the bottle was not labeled. There is no unifying primary event—they each happened independently. If the patient gets an incorrect dose of one medication and has another omitted because the bottle was labeled incorrectly, then it is one event because the incorrect dose and omission are direct results of the bad label (see Scenario 3, below). |
| 3 | Patients A and B are supposed to each get a mixture of the same three medications, though the proportions of the medications are different. The medications are both mixed, then the labels printed. In applying the labels, they are switched and Patient A and B each receive the other’s medication. | Incorrect/incomplete labeling | This is one medication event, incorrect label, because the subsequent incorrect medication would have been avoided if the bottles been correctly labeled. |
History
Start Date | Spring 2012 |
|---|---|
End Date | n/a |
Change History | May 2013: HIT removed as an event type. HIT was too hard to define as an event type, so it was moved into "Additional event questions" to be asked of all events. Additional specification added to Surgical or other invasive procedure and HAI. 2014: Prompt updated. January 2015: updated "Unintended retained foreign object" to "Unintended retained foreign object (includes retained surgical items)." |
Field Name | event_type |