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

Anesthesia

Patient death or serious injury associated with anesthesia.

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 patient”); anesthetic medication (submit as “medication or other substance”); problem with device used in the delivery of anesthesia (submit as “device or medical/surgical supply”)

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

Burn (unrelated to the use or misuse of a device or medical/surgical supply)

Patient death or serious physical injury associated with a burn incurred from any source other than the use or misuse of a device or medical/surgical supply while being cared for in a healthcare facility.

INCLUDES: burn caused by something other than a piece of equipment or medical/surgical supply (e.g. hot water, sunburn, smoking in patient care environment)

EXCLUDES: burn caused by a piece of equipment or medical/surgical 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”)

Contaminated, wrong or no gas given to a patient

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”)

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

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

Healthcare-Associated Infection (HAI)

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, (e.g. 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”)

Irretrievable loss of an irreplaceable biologic 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

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”)

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

• dehiscence, flap or would failure or disruption, or graft failure

• endoscopies

• iatrogenic pneumothorax

• incorrect implant

• injection into joints

• laceration

• lens implants

• lesion removal

• nick

• perforation

• postop bleeding requiring return to operating room

• puncture

• unintended blockage, obstruction, or ligation

• unplanned removal of an organ

• wrong graft tissue

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

Spring 2012

n/a

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”).