Description
Determination of the nursing facility event type that is being reported.
On-Screen Instructions
Select all that apply.Field Type
Checkbox (multiselect)
Responses
Aspiration
Patient/resident death or serious injury associated with an aspiration.
Includes
Aspiration pneumonia or chemical pneumonia (select both Aspiration and Healthcare-associated infection (HAI) events)
Excludes
No additional information provided.Burn (unrelated to the use or misuse of a device)
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 (select Device or supply (including use error) event)
Care delay (including delay in treatment, diagnosis)
Patient/resident 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.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
Contractures
Patient/resident death or serious injury associated with development of a contracture.
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)
Dehydration
Patient/resident death or serious injury associated with not receiving sufficient fluid intake to maintain proper hydration and health.
“Sufficient fluid” means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health. The amount needed is specific for each patient/resident, and fluctuates as the patient/resident’s condition fluctuates (e.g., increase fluids if patient/resident has fever or diarrhea).
Device or medical supply (including use error)
Patient/resident death or serious injury associated with the use or function of a device or medical/surgical supply in patient/resident care, in which the device is used or functions other than as intended.
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
No additional information provided.Event-Type Specific Questions |
Diabetic coma
Patient/resident death or serious injury associated with a diabetic coma.
Includes
Diabetic coma related to hypoglycemia or hyperglycemia
Excludes
No additional information provided.Discharge or release of a patient/resident of any age, who is unable to make decisions, to an unauthorized person
Discharge or release of a patient/resident of any age, who is unable to make decisions, to an unauthorized person.
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
Elopement
Patient/resident death or serious injury associated with patient/resident elopement (disappearance).
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
Fall
Patient/resident 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/resident lost their 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/resident is found on the floor, a fall is considered to have occurred.
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
Event-Type Specific Questions |
Additional Support |
Fecal impaction
Patient/resident death or serious injury associated with fecal impaction.
Healthcare-associated infection (HAI)
Patient/resident death or serious injury associated with an infection acquired while being cared for in a healthcare setting.
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
Event-Type Specific Questions |
Additional Support |
Intravascular embolisms related to IV therapy
Patient/resident death or serious injury associated with intravascular air embolism that occurs as a result of being cared for with IV therapy in a healthcare facility.
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
No additional information provided.Medication or other substance
Patient/resident 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
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
Event-Type Specific Questions |
Pressure injury
Any Stage 3, Stage 4, and unstageable pressure injuries acquired after admission, or that was present on admission and fails to show some evidence of progress toward stabilization or healing within 2-4 weeks.
“Unavoidable” means that the patient/resident developed a pressure injury even though the facility had evaluated the patient/resident’s clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with patient/resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.
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.
Event-Type Specific Questions |
Patient/Resident transfer related
Patient/resident death or serious injury associated with transferring from one surface (seated or laying down) to another (e.g., bed, chair, wheelchair, toilet)
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)
Restraint or bedrail related
Patient/resident 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
Suicide (select Suicide or attempted suicide)
Strangulation
Patient/resident death or serious injury associated with unintentional strangulation.
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)
Suicide or attempted suicide
Patient/resident suicide or attempted suicide resulting in serious physical injury, while being cared for in a healthcare facility.
Includes
Events that result from patient/resident 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
Other event
Patient/resident 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/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
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 | 2007 |
|---|---|
End Date | n/a |
Change History | Spring 2012: The event type “Treatment related” was been split into “Contractures,” “Dehydration,” “Diabetic coma,” “Fecal impaction,” “Intravascular embolisms related to IV therapy,” and “Pressure ulcer.” |
Field Name | event_type |