Data Dictionary - Oregon Patient Safety Commission · The data dictionary provides detailed descriptions of each element in the reporting form. If you have questions or need more

The data dictionary provides detailed descriptions of each element in the reporting form. If you have questions or need more information about a particular reporting form question, use the data dictionary to locate specific information about that question. If questions remain after you have consulted the data dictionary, please contact the Commission at 971-266-8079 or [email protected].

How to Use This Document

Each item on the reporting form will appear in its own table including (but not limited to) the following information: question location on the form; question description; responses, where relevant; and a short guide for use, where relevant. The following table defines each row of any given data dictionary table. The tables appear in the same order as on the form. Please use the bookmarks and search features in this document to locate the information you are looking for.

If you need additional assistance or have questions about this document, please contact your patient safety consultant for additional information.

Example of Information Provided in this Data Dictionary

[Question text as it appears in the online form]

Question Location [Indicates on which tab the question can be found in the online form]

Description [Describes the data the question is intended to gather]

Prompt [Provides additional information needed to answer the question as it appears on the online form]

Responses [Lists the possible responses options for multiple choice questions in the order in which they appear on the form]

Go-To Logic [Explains what triggers the appearance of this question, where relevant] [Explains which additional questions will appear based on your answer to this question, where relevant]

Required [Indicates if the question is required; i.e., Yes/No]

Question Type [Indicates the format in which the question appears on the online form (e.g.,. date, text input, dropdown menu, checkbox, etc.)]

Maximum Length [Indicates the maximum length a response can be (i.e., number of characters allowed), if applicable]

Minimum Value [Indicates the lowest value a number field will accept, if applicable]

Maximum Value [indicates the highest value a number field will accept, if applicable]

Guide for Use [Provides instructions for how to answer this question; e.g., additional information to answer the question, when to answer it, inclusions, exclusions, etc.]

NURSING FACILITY Patient Safety Reporting Program

Data Dictionary

mailto:[email protected]

http://oregonpatientsafety.org/reporting-programs/

http://oregonpatientsafety.org/reporting-programs/

Updated: 12/11/2017 Data Dictionary for Nursing Facilities 2

Content Quick Links

How to Use This Document 1

Example of Information Provided in this Data Dictionary 1

Content Quick Links 2

General Information Tab 3

Harm Category Tab 7

Event Tab 12

Contributing Factors Tab 15

Review Tab 20

Summary Tab 22

Additional Questions 24

Device or Medical Supply (Including Use Error) Event 24

Fall Event 26

Healthcare-Associated Infection (HAI) Event 32

Medication or Other Substance Event 35

Pressure Ulcer Event 40

Appendix I: List of Facilities and Nursing Facility Corporations 45

Appendix II: Harm Categories and Algorithm 48

Appendix III: Event Type Descriptions 50

Appendix IV: Healthcare-Associated Infection Event Type Descriptions 54

Appendix V: Medication or Other Substance Event Type Descriptions 55

Appendix VI: Contributing Factor Descriptions 58

Communication 58

Device, equipment, or supply 61

Human or environmental 63

Organizational 64

Policy or procedure 67

Patient management 68

Patient 69


General Information Tab

Event date Question Location General Information Tab Description Date event generating report occurred Prompt n/a Go-To Logic n/a Required Yes Question Type Date

Format mm/dd/yyyy Guide for Use Date the event generating the report occurred, not the date that harm occurred.

Event time Question Location General Information Tab Description Time event generating report occurred Prompt Use military time (hhmm) Go-To Logic n/a Required Yes Question Type Text Input

Format hhmm Maximum Length 5 Minimum Value 0000 Maximum Value 2359 Guide for Use If time is unknown, mark the checkbox “unknown.”

Date discovered Question Location General Information Tab Description Date the facility/organization first became aware of the event. Prompt The date that the facility/organization first became aware of the event. Go-To Logic n/a Required Yes Question Type Date

Format mm/dd/yyyy Guide for Use The date that the facility/organization first became aware of the event. This may or may not

be the same as the event date (e.g., Medication or other substance event discovered upon record review, Fall reported by family member days after event occurred).

When was the DNS or Administrator notified of the event? Question Location General Information Tab Description Date DNS or Administrator was notified of the event. Prompt If both were notified, use the earliest date. Go-To Logic n/a Required Yes Question Type Date

Format mm/dd/yyyy Guide for Use If both were notified, use earliest date.

Select your corporation Question Location General Information Tab Description Reporting facility’s organization Prompt If your nursing facility is not part of a larger organization, please choose "independent."


Responses Avamere Dakavia Extendicare Good Samaritan Society Independent Lake Health District Life Care Centers of America Marquis Companies Pacific Retirement Services Pinnacle Prestige Providence Health & Services Regency Pacific

Go-To Logic n/a Required Yes Question Type Auto-populated dropdown menu Guide for Use No further information provided.

Select your facility Question Location General Information Tab Description Determination of which facility is reporting. Prompt n/a Responses Depends on corporation selected. A full list is available in Appendix I: List of facilities and

nursing facility corporations. Go-To Logic n/a Required Yes Question Type Select Dropdown Guide for Use See Appendix I for List of Facilities and Nursing Facility Corporations.

Patient’s gender Question Location General Information Tab Description Patient/resident’s self-identified gender Prompt Please use the patient’s self-identified gender. Responses Female

Male Go-To Logic n/a Required Yes Question Type Select Dropdown Guide for Use Note: If you are reporting an event that impacted multiple patients/residents, please

complete a separate form for each patient/resident with their specific demographic data. Other sections of the form may be copied and pasted. If you have questions about this procedure, please contact a patient safety consultant.

Patient’s age Question Location General Information Tab Description Patient/resident’s age at the time of the event being reported. Prompt n/a Go-To Logic n/a Required Yes Question Type Number Maximum Length 3 Minimum Value 0


Maximum Value 128 Guide for Use Note: If you are reporting an event that impacted multiple patients/residents, please


Age unit Question Location General Information Tab Description Unit of time in which patient/resident’s age is measured Prompt n/a Responses Years

Months Weeks Days

Default Years Go-To Logic n/a Required Yes Question Type Select Dropdown Guide for Use Select the appropriate unit for the patient/resident’s age. Always choose “years” unless the

patient is less than one year of age.

Note: If you are reporting an event that impacted multiple patients/residents, please complete a separate form for each patient/resident with their specific demographic data. Other sections of the form may be copied and pasted. If you have questions about this procedure, please contact a patient safety consultant.

Patient’s race Question Location General Information Tab Description Patient/resident’s self-identified race. Prompt Check all that apply. Responses American Indian or Alaskan Native

Asian Black or African American Native Hawaiian or Pacific Islander White Other Unknown

Go-To Logic n/a Required Yes Question Type Checkboxes Guide for Use Note: If you are reporting an event that impacted multiple patients/residents, please


Patient’s ethnicity Question Location General Information Tab Description Patient/resident’s self-identified ethnicity. Prompt Check one. Responses Hispanic

Not Hispanic Unknown


Go-To Logic n/a Required Yes Question Type Radio Buttons Guide for Use Note: If you are reporting an event that impacted multiple patients/residents, please


Contact name Question Location General Information Tab Description Name of participant facility’s Patient Safety Reporting Program contact person Prompt Who should we contact for clarification or feedback? Go-To Logic n/a Required Yes Question Type Text Input Maximum Length 128 Guide for Use No further information provided.

Contact email address Question Location General Information Tab Description Name of participant facility’s Patient Safety Reporting Program contact person Prompt n/a Go-To Logic n/a Required No Question Type Text Input

Format: must be a valid email address Maximum Length 100 Guide for Use No further information provided.

Contact phone Question Location General Information Tab Description Name of participant facility’s Patient Safety Reporting Program contact person Prompt n/a Go-To Logic n/a Required Yes Question Type Text Input

Format: (xxx) xxx-xxxx Maximum Length 15 Guide for Use No further information provided.

Contact extension Question Location General Information Tab Description Name of participant facility’s Patient Safety Reporting Program contact person Prompt n/a Go-To Logic n/a Required No Question Type Text Input Maximum Length 10 Guide for Use No further information provided.


Harm Category Tab

Did an actual adverse event occur? Question Location Harm Category Tab Description Determination of whether or not an adverse event occurred. Prompt Adverse event: an event resulting in unintended harm or creating the potential for harm that

is related to any aspect of a patient’s care (by an act of commission or omission) rather than to the underlying disease or condition of the patient. Adverse events may or may not be preventable.)

Responses Yes No

Go-To Logic If “yes,” opens the question “Did the event reach the patient?” If “no,” assigns harm category A (circumstances that have the capacity to cause harm) and section is complete.

Required Yes Question Type Radio buttons Guide for Use See Appendix II for Harm Categories and Algorithm.

Did the event reach the patient? Question Location Harm Category Tab Description Determination of whether or not the event reached the patient/resident. Prompt An error of omission does reach the patient. Responses Yes

No Go-To Logic Only appears if the question “Did an actual adverse event occur” was answered “yes.”

If “yes,” opens the question “Did the event contribute to or result in patient death?” If “no,” assigns harm category B (event occurred that did not reach the patient) and opens the question “What prevented the event from reaching the patient?”

Required If this question appears on your form, it is required. Question Type Radio buttons Guide for Use See Appendix II for Harm Categories and Algorithm.

Did the event contribute to or result in patient death? Question Location Harm Category Tab Description Determination of whether or not the event resulted in or contributed to the

patient/resident’s death. Prompt n/a Responses Yes

No Go-To Logic Only appears if the question “Did the event reach the patient?” is answered “yes.”

If “yes,” assigns harm category I (event may have contributed or resulted in patient’s death) and section is complete. If “no,” opens the question “Was the patient harmed?”


Was the patient harmed? Question Location Harm Category Tab Description Determination of whether or not the patient/resident was harmed. Prompt Harm: any physical injury or damage to the health of a person requiring additional medical


care, including both temporary and permanent injury. Responses Yes

No Go-To Logic Only appears the question “Did the event contribute to or result in patient death?” is

answered “no.” If “yes,” opens the question “Was an intervention necessary to sustain life required?” If “no,” opens the question “Was an intervention to preclude harm/extra monitoring required?”


Was an intervention to preclude harm/extra monitoring required? Question Location Harm Category Tab Description Determination of whether or not extra monitoring or an intervention to preclude harm was

required. Prompt Monitoring: to observe or record physiological or psychological signs. Responses Yes

No Go-To Logic Only appears if the question “Was the patient harmed?” is answered “no.”

If “yes,” assigns harm category D (event reached patient and required monitoring to confirm that it resulted in no harm and/or required intervention to preclude harm) and opens the question “Which intervention to preclude harm was required?” If “no,” assigns harm category C (event reached patient but did not cause patient harm) and section is complete.


Was an intervention necessary to sustain life required? Question Location Harm Category Tab Description Determination of whether or not an intervention necessary to sustain life was required. Prompt Intervention necessary to sustain life: includes cardiovascular and/or respiratory support

(e.g., CPR, defibrillation, intubation, etc.). Responses Yes

No Go-To Logic Only appears if the question “Was the patient harmed?” is answered “yes.”

If “yes,” opens the question “Was the harm permanent?” If “no,” opens the question “Was the harm temporary?”


Was the harm permanent? Question Location Harm Category Tab Description Determination of whether or not patient/resident harm was permanent. Prompt Permanent harm: harm lasting more than 6 months or where the end harm is not known. Responses Yes

No Go-To Logic Only appears if the question “Was an intervention necessary to sustain life required?” is

answered “yes.” If “yes,” assigns harm category G (event may have contributed to or resulted in permanent


patient harm). If “no,” assigns harm category H (event required intervention necessary to sustain life).

Required If this question appears on your form, it is required. Question Type Radio buttons Guide for Use See Appendix II for Harm Categories and Algorithm. Pressure ulcers Stage III and above are always

permanent harm.

Was the harm temporary? Question Location Harm Category Tab Description Determination of whether or not patient/resident harm was temporary. Prompt n/a Responses Yes

No Go-To Logic Only appears if the question “Was an intervention necessary to sustain life required?” is

answered “no.” If “yes,” opens the question “Did the event require any of the following significant interventions?” If “no,” assigns harm category G (event may have contributed to or resulted in permanent patient harm).

Required If this question appears on your form, it is required. Question Type Radio buttons Guide for Use Pressure ulcers Stage III and above are always permanent harm.

Did the event require any of the following significant interventions? Question Location Harm Category Tab Description Determination of the intervention(s) performed as a result of the adverse event. Prompt Check all that apply. A “significant intervention” is an intervention intended to relieve

symptoms that have the potential to be life-threatening if not addressed. Responses Move to a higher level of care

Surgical/procedural intervention Medication therapy (including administration of rescue drug or antidote) Other significant intervention (please describe) No significant intervention

Go-To Logic Only appears if the question “Was the harm temporary?” is answered “yes.” If “No significant intervention” is selected, no other response can also be selected, the form assigns harm category E (event may have contributed to or resulted in temporary harm but did not require significant intervention) and section is complete. If any response(s) other than “No significant intervention” is selected, assigns harm category F (event may have contributed to or resulted in temporary harm and required a significant intervention) and section is complete. If “other significant intervention,” a text box for description will also open.

Required If this question appears on your form, it is required. Question Type Checkboxes Guide for Use A “significant intervention” is an intervention intended to address a condition or relieves

symptoms resulting from a condition that has the potential to cause additional serious physical injury or to be life-threatening if not addressed. Move to a higher level of care INCLUDES:

• Hospitalization, regardless of level of care in nursing facility upon return

• Moving to hospice, comfort care or palliative care as a result of the event Medication therapy INCLUDES:


• Administration of a rescue drug or antidote (e.g. narcan, epinephrine) Surgical/procedural intervention INCLUDES:

• I&D (incision and drainage)

• ORIF (hip surgery) post-fall Other significant intervention INCLUDES:

• Respiratory support

• Unplanned blood transfusion

The Harm Category for this event is: Question Location Harm Category Tab Description Harm category assigned by answering questions adapted from the NCC-MERP Harm Category

Algorithm. Prompt n/a – harm category automatically assigned by reporting system Responses Category A

Circumstances that have the capacity to cause an adverse event

Category B

An event occurred that did not reach the patient (an “error of omission” does reach the

patient)

Category C

An event occurred that reached the patient but did not cause patient harm

Category D

An event occurred that reached the patient and required monitoring to confirm that it resulted

in no harm to the patient and/or required intervention to preclude harm

Category E

An event occurred that may have contributed to or resulted in temporary harm to the patient

but did not require significant intervention

Category F

An event occurred that may have contributed to or resulted in temporary harm to the patient

and required a significant intervention

Category G

An event occurred that may have contributed to or resulted in permanent patient harm

Category H

An event occurred that required intervention necessary to sustain life

Category I

An event occurred that may have contributed to or resulted in patient’s death Go-To Logic n/a – harm category automatically assigned by reporting system Required n/a – harm category automatically assigned by reporting system Question Type n/a – harm category automatically assigned by reporting system Guide for Use If you chose more than one event type, please select the highest applicable level of harm. See

Appendix II for Harm Categories and Algorithm.

What prevented the event from reaching the patient? Question Location Harm Category Tab Description Determination of what process prevented the near miss from reaching the patient/resident. Prompt n/a Responses Fail-safe/safeguard worked effectively


Action by a practitioner or staff who made the error prevented the event form reaching the patient

Action by a practitioner or staff member (other than person making the error) prevented the event from reaching the patient

Action by the patient or patient’s family member prevented the event from reaching the patient

Unknown Other (please describe)

Go-To Logic Only appears if harm category is B. If “other,” a text box for description will also open.

Required No Question Type Select Dropdown Guide for Use The answer selections are intended to be mutually exclusive. However, if it appears to you

that “Fail-safe/safeguard worked effectively” and one of the other selections both apply, select “Fail-safe/safeguard worked effectively.”

Which intervention to preclude harm was required? Question Location Harm Category Tab Description Specification of intervention(s) performed as a result of the adverse event to preclude harm. Prompt Check all that apply. Increased length of stay

Monitoring, including observation, physiological examination, laboratory testing, phlebotomy, and/or imaging studies

Medication therapy (excluding administration of rescue drug or antidote) Other intervention (please describe)

Go-To Logic Only appears if harm category is D. If “other intervention,” a text box for description will also open.

Required If this question appears on your form, it is required. Question Type Checkboxes Guide for Use Increased length of stay

INCLUDES:

• Additional time in the facility for monitoring or observation EXCLUDES:

• Does not apply to long-term care residents

• Prolonged stay in the facility for additional surgery or other invasive procedure. If an additional surgery or other invasive procedure is required, the patient/resident suffered harm.

Monitoring INCLUDES:

• Observation

• Physiological examination

• Laboratory testing

• Phlebotomy

• Imaging studies Medication therapy INCLUDES:

• Change in pre-incident dose or route EXCLUDES:

• Administration of a rescue drug or antidote. If a rescue drug or antidote was required, the patient/resident suffered harm.

Other intervention

• No further information provided


Event Tab

Event Type Question Location Event Tab Description Determination of the event type that is being reported. Prompt 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.

Responses Aspiration Burn (unrelated to the use or misuse of a device) Care delay (including delay in treatment, diagnosis) Choking Contractures Dehydration Device or medical supply (including use error)* Diabetic coma Discharge or release of a patient/resident of any age, who is unable to make decisions, to an

unauthorized person Elopement Fall* Fecal impaction Healthcare-associated infection (HAI)* Intravascular embolisms related to IV therapy Medication or other substance* Pressure ulcer* Resident transfer related Restraint or bedrail related Strangulation Suicide or attempted suicide Other event (please describe)

Go-To Logic If “other,” a text box for description will also open. If any of the following event types are selected (indicated by a * in the response list above), additional event specific questions will populate after “Additional Event Information” as indicated below:

Device or medical supply (including use error) “Which best describes the event?”, “Type of device or supply involved,” and “Was the event reported to MedWatch?”

Fall “Was a fall risk assessment documented?”, “Was the patient/resident assessed to be at any level of risk for a fall?”, “Date of most recent falls assessment,” “Why was the most recent fall assessment performed?”, “Was the patient/resident on medication known to increase fall risk at the time of the fall?”, “Was the medication considered to have contributed to the fall?”, “Were any of the following risk factors present at the time of the fall?”, “Were any of the following risk factors considered to have CONTRIBUTED to the fall?”, “Which of the following were in the patient/resident’s care plan to prevent falls?”, “Which of the following were in place and being used to prevent falls for this patient/resident?”, “Prior to the fall, what was the patient/resident doing or trying to do?”, “What was the patient/resident’s goal? Why did s/he get up or try to get up?”, “Was the fall observed?”, “Was the fall assisted or unassisted?”, “Did any physical device contribute to the fall?”, “What was the physical or environmental cause of the fall?”, “Did the patient/resident sustain a physical injury as a result of the fall?”, and “What type of


injury was sustained?”

Healthcare-associated infection (HAI) “Type of healthcare-associated infection (HAI)”, “Was the infection determined to be present or incubating on admission?” and “Type of pathogen.”

Medication or other substance “Type of medication or other substance event”, “What type of medication/substance was involved?”, “Generic name or investigational drug name(s)”, “Was this medication/substance prescribed for this patient/resident?”, “Was this medication/substance given to this patient/resident?”, “At what stage in the process did the event originate, regardless of the stage at which it was discovered?” and “Were any of the following involved?”

Pressure ulcer “Most advanced stage of pressure ulcer being reported”, “What was the stage on admission of the pressure ulcer?”, “Pressure ulcer location”, “On admission to the facility, was a skin inspection documented?”, “When was the first pressure ulcer risk assessment documented?”, “Was any preventive intervention implemented?”, and “Was the use of a device or appliance involved in the development or advancement of the pressure ulcer?”

Required Yes Question Type Checkboxes Guide for Use See Appendix III: Event Type Definitions for further guidance. You may also want to refer to

the PSRP Corner article on this topic (https://oregonpatientsafety.org/blog/blog/which-event-type-should-i-select/681/).

Event location Question Location Event Tab Description Determination of where the event occurred or where the unsafe condition existed. Prompt Select the location where the event occurred, or originated, regardless of the location in

which it was discovered Responses Activity/recreation room

Bathroom (toileting, bathing, tub/shower room) Dining room Other area within the facility (beauty/barber shop, elevator, hallway, nurses’ station, stairs,

etc.) Outside area Rehab/therapy room Resident room Other (please describe)

Go-To Logic If “other,” a text box for description will also open. Required Yes Question Type Select Dropdown Guide for Use Select the answer that best describes the location of the event as specifically as possible. For

locations that fall under two categories (such as a bathroom in a resident’s room), choose the more specific location (in the case of the example, the bathroom). You may also want to refer to the PSRP Corner article on this topic (https://oregonpatientsafety.org/blog/blog/how-do-i-choose-the-correct-event-location/627/).

Relevant comorbidities Question Location Event Tab Description Brief description of patient/resident comorbidities related to the event. Prompt Please list comorbidities related to the reported event. Go-To Logic n/a

https://oregonpatientsafety.org/blog/blog/which-event-type-should-i-select/681/

https://oregonpatientsafety.org/blog/blog/which-event-type-should-i-select/681/

https://oregonpatientsafety.org/blog/blog/how-do-i-choose-the-correct-event-location/627/

https://oregonpatientsafety.org/blog/blog/how-do-i-choose-the-correct-event-location/627/


Required No Question Type Text Input Guide for Use An existing medical condition or disease process that played a role in the adverse event.

Level of care Question Location Event Tab Description Determination of patient/resident’s level of care in your facility at the time of event. Prompt The patient/resident’s level of care in your facility at the time of the event. Responses Long-term care or intermediate care

Skilled nursing care Other (please describe)

Go-To Logic If “other,” a text box for description will also open. Required No Question Type Text Input Guide for Use The determination of the patient/resident’s level of care in your facility at the time of the

event. If the resident was receiving Hospice care or another level of care not provided, please select “other” and indicate the level of care the patient/resident was receiving.

How preventable was the incident? Question Location Event Tab Description Determination of how preventable the specific incident being reported was. Prompt n/a Responses Almost certainly could have been prevented

Likely could have been prevented Likely could not have been prevented Almost certainly could not have been prevented Unknown

Go-To Logic This question only appears if the Harm Category is C, D, E, F, G, H or I. Required No Question Type Dropdown select Guide for Use No further information provided.

For event-specific additional questions, see “Additional Questions” section of data dictionary, following “Summary Tab” section.


Contributing Factors Tab

Communication Question Location Contributing factors tab Description Determination if any contributing factor(s) related to communication are known. Prompt Were communication factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Communication factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Communication factors Question Location Contributing factors Description Determination of which contributing factor(s) related to communication are known. Prompt Check all that apply. Responses Among healthcare team members

Across units Among interdisciplinary teams Between providers and staff Between supervisor and staff Handoffs, handovers or shift reports Hard to read fax or handwriting Within units With other organizations or outside providers Other (please describe) With patients/families Culture Language Miscommunication Patient/resident did not use call light Patient/resident unable to communicate Other (please describe)

Go-To Logic This question only appears if “Communication” was answered “yes.” If “other,” a text box for description will also open.

Required If “Communication” is answered “yes,” then one of these options must be selected. Otherwise it is not required.

Question Type Checkboxes Guide for Use See Appendix VI: Contributing Factor Descriptions for further guidance.

Device, equipment, or supply Question Location Contributing factors Description Determination if any contributing factor(s) related to devices, equipment, or supplies are

known. Prompt Were device, equipment, or supply factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Device equipment, or supply factors.” Required Yes Question Type Radio Buttons


Guide for Use No further information provided.

Device, equipment, or supply factors Question Location Contributing factors Description Determination of which contributing factor(s) related to devices, equipment, or supplies are

known. Prompt Check all that apply. Responses Availability

Design Function (e.g., defective, non-working) Maintenance Shortage Use or selection by healthcare provider or staff Use by patient Other (please describe)

Go-To Logic This question only appears if “Device, equipment, or supply” was answered “yes.” If “other,” a text box for description will also open.

Required If “Device, equipment, or supply” is answered “yes,” then one of these options must be selected. Otherwise it is not required.


Human or environmental Question Location Contributing factors Description Determination if any contributing factor(s) related to human or environmental factors are

known. Prompt Were human or environmental factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Human and environmental factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Human or environmental factors Question Location Contributing factors Description Determination of which contributing factor(s) related to human or environmental factors are

known. Prompt Check all that apply. Responses Alarm fatigue

Clutter Interruptions/distractions Lighting Noise Provider or staff fatigue Provider or staff health issues Provider or staff stress Work area design and specifications Other (please describe)

Go-To Logic This question only appears if “Human and environmental” was answered “yes.” If “other,” a text box for description will also open.


Required If “Human and environmental” is answered “yes,” then one of these options must be selected. Otherwise it is not required.


Organizational Question Location Contributing factors Description Determination if any contributing factor(s) related to the organization are known. Prompt Were organizational factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Organizational factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Organizational factors Question Location Contributing factors Indicate which organizational factor(s). Description Determination of which contributing factor(s) related to the organization are known. Prompt Check all that apply. Responses Adequacy of budget

Assignment or work allocation Culture of safety Internal reporting Job orientation or training Management or leadership skills Staff competencies Staffing levels Staffing turnover Supervision Systems to identify risk Temporary staffing Other (please describe)

Go-To Logic This question only appears if “Organizational” was answered “yes.” If “other,” a text box for description will also open.

Required If “Organizational” is answered “yes,” then one of these options must be selected. Otherwise it is not required.


Policy or procedure Question Location Contributing factors Description Determination if any contributing factor(s) related to policies or procedures are known. Prompt Were policy or procedure factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Policy or procedure factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.


Policy or procedure factors Question Location Contributing factors Description Determination of which contributing factor(s) related to policies or procedures are known. Prompt Check all that apply. Responses Clarity of policy or procedure

Policy or procedure absent Provider or staff unfamiliar with policy or procedure Policy or procedure too cumbersome Work-around more efficient Other (please describe)

Go-To Logic This question only appears if “Policy or procedure” was answered “yes.” If “other,” a text box for description will also open.

Required If “Policy or procedure” is answered “yes,” then one of these options must be selected. Otherwise it is not required.


Patient/resident management Question Location Contributing factors Description Determination if any contributing factor(s) related to patient/resident management are

known. Prompt Were patient/resident management factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Patient/resident management factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Patient/resident management factors Question Location Contributing factors Indicate which patient/resident management factor(s). Description Determination of which contributing factor(s) related to patient/resident management are

known. Prompt Check all that apply. Responses Accuracy of care plan

Follow-up care Implementation of care plan Initial diagnosis Patient/resident assessment Response to changing condition or delay in care Other (please describe)

Go-To Logic This question only appears if “Patient/resident management” was answered “yes.” If “other,” a text box for description will also open.

Required If “Patient/resident management” is answered “yes,” then one of these options must be selected. Otherwise it is not required.


Patient/resident Question Location Contributing factors Description Determination if any contributing factor(s) related to patient/residents are known.


Prompt Were patient/resident factors involved in this event? Responses Yes

No Go-To Logic If “yes,” opens the question “Patient/resident factors.” Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Patient/resident factors Question Location Contributing factors Description Determination of which contributing factor(s) related to patient/residents are known. Prompt Check all that apply. Responses Behavioral status

Family dynamics or relationships Fragile health status Mental status Physical limitations Sensory impairment (vision, hearing, balance, etc.) Other (please describe)

Go-To Logic This question only appears if “Patient/resident” was answered “yes.” If “other,” a text box for description will also open.

Required If “Patient/resident” is answered “yes,” then one of these options must be selected. Otherwise it is not required.



Review Tab

Date review and analysis completed Question Location Review tab Description Date the investigation team completed its review and analysis of the event. Prompt n/a Go-To Logic n/a Required Yes Question Type Date

Format: mm/dd/yyyy Guide for Use No further information provided.

Members of the review and analysis team Question Location Review tab Description Determination of the job roles of the members of the review and analysis team. Prompt Check all that apply. Responses Activities manager/staff

Dietary staff Direct care staff Family/patient or patient/resident or resident representative Housekeeping/maintenance Registered/licensed nurse Nursing management (e.g., DNS or Resident Care Manager) Pharmacist(s) Physician(s) Rehabilitation staff Senior management/administrator Social services Other (please describe)

Go-To Logic If “other,” a text box for description will also open. Required Yes Question Type Checkboxes Guide for Use No further information provided.

Person hours spent in review Question Location Review tab Description Number of person hours spent in the review and analysis process. Prompt Please approximate the combined total number of hours that all individuals involved

contributed to the review and analysis of this event. Go-To Logic n/a Required Yes Question Type Number Guide for Use See the PSRP Corner article on this topic (https://oregonpatientsafety.org/blog/psrp-

corner/psrp-corner-how-do-i-calculate-person-hours-in-review-in-my-report/559).

Did the review and analysis team have a post-analysis briefing with the interdisciplinary team? Question Location Review tab Description Determination of whether or not the review and analysis team briefed the interdisciplinary

team after completing their review and analysis. Prompt n/a

https://oregonpatientsafety.org/blog/psrp-corner/psrp-corner-how-do-i-calculate-person-hours-in-review-in-my-report/559

https://oregonpatientsafety.org/blog/psrp-corner/psrp-corner-how-do-i-calculate-person-hours-in-review-in-my-report/559


Responses Yes No

Go-To Logic n/a Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Who was given written notification? Question Location Review tab Description Determination of who was given written notification of the event. Prompt Check all that apply. Responses Patient/resident

Patient/resident’s representative None given

Go-To Logic If “none given,” opens the question “Please specify why no written notification was given.” Required Yes Question Type Checkboxes Guide for Use No further information provided.

Please specify why no written notification was given Question Location Review tab Description Determination of why no one was given written notification of the event. Prompt Check all that apply. Responses Written notification pending

No organizational policy Not required by facility organizational policy Not required by Commission definitions Oral disclosure Unable (please describe) Other (please describe)

Go-To Logic This question only appears If “Who was given written notification?” is answered “none given.” If “other” or “unable,” a text box for description will also open.

Required No Question Type Checkboxes Guide for Use No further information provided.


Summary Tab

Instructions: The Commission evaluates reports to support healthcare organizations in conducting in-depth investigations focused on preventing future adverse events. Acceptable quality is determined using four criteria: completeness, thoroughness, credibility, and effective action plans (see the Quality Criteria document in the Tools and Resources menu above).

Please do not use patient, provider, or facility names to describe the adverse event. If you want to refer to a specific healthcare provider, please use general terms (for example, use a generic description, such as doctor or nurse 1).

Complete account Question Location Summary Tab Description Complete, narrative account of event. Prompt Briefly summarize the circumstances leading up to the event. The summary should describe

the role contributing factors played and the system practices and processes involved, and may briefly describe relevant patient clinical progress. Include enough information so that someone unfamiliar with the event could easily understand how the event happened.

Go-To Logic n/a Required Yes Question Type Text area (memo field) Maximum length None Guide for Use You may also want to refer to the PSRP Corner article on this topic

(https://oregonpatientsafety.org/blog/blog/what-information-should-i-include-in-the-complete-account/641/).

Causes and Action Plans Instructions: For the following questions, identify up to five causes and associated action plans that your organization will take to prevent occurrence of similar events. Include at least one root cause and one system-level action plan. Show a clear link between the cause and the action plan. A root cause identifies underlying processes and gaps in practice related to the event. A system-level action plan focuses on processes, practices, and procedures, rather than individuals, and has the greatest likelihood of preventing future occurrences. (Note: you do not need to describe your implementation plan.)

Cause Question Location Summary Tab Description Cause or finding from event review and analysis. Prompt n/a Go-To Logic n/a Required Yes Question Type Text area (memo field) Maximum length None Guide for Use No further information provided.

Is this a root cause? Question Location Summary Tab Description Determination of whether or not cause or finding was a root cause. Prompt n/a Responses Yes

No Go-To Logic n/a Required Yes

https://oregonpatientsafety.org/blog/blog/what-information-should-i-include-in-the-complete-account/641/

https://oregonpatientsafety.org/blog/blog/what-information-should-i-include-in-the-complete-account/641/


Question Type Radio Buttons Guide for Use A “root cause” is a condition or circumstance that prompted an action that led to the event or

near miss occurrence or harm. The most basic cause(s) are often several steps removed from the action (or inaction) that precipitated the event or near miss. Correction of a root cause within the system can prevent (or significantly reduce the likelihood of) the recurrence of the event or near miss.

Action Plan Question Location Summary Tab Description The action plan that addresses the cause or finding and is designed to prevent occurrence of

similar events. Prompt n/a Go-To Logic n/a Required Yes Question Type Text area (memo field) Maximum length None Guide for Use No further information provided.


Additional Questions

Device or Medical Supply (Including Use Error) Event

Which best describes the event? Question Location Event Tab – Additional Questions Section Description Determination of the best description of the device or medical supply adverse event. Prompt Check all that apply. Responses Device or supply failure

Use error Device or supply not available Device or supply expired Unknown Other (please describe)

Go-To Logic This question only appears if the event type is Device or medical supply (including use error). If “other,” a text box for description will also open.

Required Yes, if event type is Device or medical supply (including use error). Question Type Checkboxes Guide for Use Device failure

INCLUDES:

• Parts falling off permanent equipment or equipment collapsing

• Programmed alarms failing to sound

• Equipment used after the end of its useful life

• Kinked tubing Use error INCLUDES:

• Use of incorrect instrument or equipment for task

• Misuse of the correct instrument or equipment (e.g., failing to lock the wheels on a wheelchair when assisting patient/resident to stand; failing to program alarms to sound at correct times, locations; mis-setting an infusion pump for any reason)

• Selection of device for use by patient that is inappropriate for that specific patient

• Use of wrong kind of sling for transfer

• Single staff person attempting to operate a two-staff person sling Device or product not available INCLUDES:

• Equipment or medical supply unavailable in correct size

• Equipment or medical supply not stored in correct location Device or product expired INCLUDES:

• Non-surgical, non-implantable device passed its expiration date (e.g., glucose test strips)

Type of device or supply involved Question Location Event Tab – Additional Questions Section Description The type of device involved in the event. Prompt Select ‘Implantable device’ if the event involved the use or function of an implant. Responses Implantable device (e.g., device intended to be permanently inserted into tissue)

Equipment (e.g., non-implantable device) Supply, including disposable product

Go-To Logic This question only appears if the event type is Device or medical supply (including use error). Required Yes, if event type is Device or medical supply (including use error). Question Type Select Dropdown


Guide for Use An Implantable device is a device that is intended to be permanently inserted into tissue. A non-implantable device is a type of Equipment. Equipment is permanent and/or reusable. Supply is disposable or single use.

Specific device Question Location Event Tab – Additional Questions Section Definition Brief description of the specific device involved in the event. Prompt Briefly describe the specific device involved in the event. Go-To Logic This question only appears if the event type is Device or medical supply (including use error). Required No Question Type Text input Maximum length 128 characters Guide for Use No further information provided.


Fall Event

Was a fall risk assessment documented? Question Location Event Tab – Additional Questions Section Description Determination if the patient/resident was assessed to be at risk for a fall. Prompt Please note: this refers to assessments performed prior to the fall. Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Fall. Required No Question Type Radio Buttons Guide for Use Select “yes” if there is any fall risk assessment documented in the patient/resident's medical

record prior to the fall. Any type of fall risk assessment will qualify. Documented fall precautions will also qualify if they are only put in place if the patient/resident is assessed to be a fall risk.

Was the patient/resident assessed to be at any level of risk for a fall? Question Location Event Tab – Additional Questions Section Description Determination if the patient/resident was at risk for a fall. Prompt n/a Responses Yes

No Unknown

Go-To Logic This question only appears if “Was a fall risk assessment documented?” is “Yes.” Required Yes Question Type Radio Buttons Guide for Use Enter the determination from the risk assessment made prior to the fall. Many fall risk

assessments use a scale of risk. Answer “yes” if the patient/resident was found to be at any level of risk.

Date of most recent fall risk assessment Question Location Event Tab – Additional Questions Section Description Determine the date of the most recent fall risk assessment Prompt n/a Go-To Logic This question only appears if the event type is Fall. Required Yes Question Type Date

Format mm/dd/yyyy Guide for Use Provide the date of the most recent fall risk assessment completed prior to the

patient/resident fall. This includes (but is not limited to) assessments completed on admission, in response to a change in the patient/resident’s condition, or as part of a standardized reassessment process (e.g., reassessing patient’s fall risk quarterly).

Why was the most recent fall assessment performed? Question Location Event Tab – Additional Questions Section Description Determination of when the patient/resident was most recently assessed for fall risk. Prompt Please note: this refers to assessments performed prior to the fall. Responses New patient/resident assessment

Quarterly assessment period Change of condition


Routine or daily shift assessment Unknown Other (please describe)

Go-To Logic This question only appears if the event type is Fall and if a fall risk assessment was documented. If “other,” a text box for description will also open.

Required Yes Question Type Radio Buttons Guide for Use No further information provided.

Was the patient/resident on medication known to increase fall risk at the time of the fall? Question Location Event Tab – Additional Questions Section Description Determination if the patient/resident was on medication known to increase the risk for a fall. Prompt Includes but is not limited to drug interactions, narcotics, hypnotics, sedatives, etc. Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Fall. If “yes”, opens the question “Was the medication considered to have contributed to the fall?”

Required Yes Question Type Radio Buttons Guide for Use Mark this question “yes” if the patient/resident:

• Was on narcotics, hypnotics, psychotropics, sedatives, and/or any other medication or substance known to increase fall risk

o This includes known idiosyncratic reactions to drugs that are not commonly associated with increased fall risk (e.g. antihistamines, antihypertensives, anti-seizure/antiepileptics, cathartics, diuretics, hypoglycemic agents, etc.)

• Had a drug interaction producing symptoms likely to increase fall risk

• Recently received anesthesia or epidural injections

Was the medication considered to have contributed to the fall? Question Location Event Tab – Additional Questions Section Description Determination if the medication was considered to have contributed to the fall. Prompt n/a Responses Yes

No Unknown

Go-To Logic This question only appears if “Was the patient/resident on medication known to increase fall risk at the time of the fall?” was answered “yes.” If “yes,” a text box for description will also open.

Required Yes Question Type Radio Buttons Guide for Use Select “Yes” if the patient/resident was on any medications that contributed to the fall. Select

“Unknown” if it is not known if the medication contributed to the fall and “No” if the medication did not contribute to the fall.

Were any of the following risk factors present at the time of the fall? Question Location Event Tab – Additional Questions Section Description Determination of risk factors present at the time of the fall. Prompt Check all that apply


Responses Cognitive impairment History of previous fall Mobility or gait impairment Prosthesis or specialty/prescription shoe Sensory impairment (vision, hearing, balance, etc.) Patient on five or more medications None Unknown Other (please describe)

Go-To Logic This question only appears if the event type is Fall. If “other,” a text box for description will also open.

Required Yes Question Type Checkboxes Guide for Use No further information provided.

Were any of the following risk factors considered to have CONTRIBUTED to the fall? Question Location Event Tab – Additional Questions Section Description Determination of risk factors present at the time of the fall that contributed to the fall. Prompt Check all that apply Responses Cognitive impairment

History of previous fall Mobility or gait impairment Prosthesis or specialty/prescription shoe Sensory impairment (vision, hearing, balance, etc.) Patient on five or more medications None Unknown Other (please describe)


Required Yes Question Type Checkboxes Guide for Use No further information provided.

Which of the following were in the patient/resident’s care plan to prevent falls? Question Location Event Tab – Additional Questions Section Description Fall prevention protocols or interventions in the patient/resident’s care plan at the time of

the fall. Prompt Indicate all protocols/interventions that were in the patient/resident’s care plan. Check all

that apply. Responses Alarms (e.g., bed, chair, tab)

Assistive devices (e.g., wheelchair, commode, cane, crutches, scooter, walker) Bed in low position Call light/personal items within reach Change in medication Hip and/or joint protectors Identified as a high fall risk Intentional rounding Non-slip floor mats Non-slip footwear Patient and family education Patient situated close to the nurses' station


Physical/occupational therapy (including exercise or mobility program) Siderails or assist rails Sitter Supplemental, environmental or area lighting (when usual facility lighting is considered insufficient) Toileting regimen Visible identification of patient/resident as being at risk for fall (e.g., Falling Star) None Unknown Other (please describe)


Required Yes Question Type Select Dropdown Guide for Use Answer this question even if no fall risk assessment was performed prior to the fall. Select

each fall risk protocol/intervention that was in the patient’s care plan to prevent falls. Please note: only individuals qualified by the facility may be considered a "sitter" for the purpose of a fall prevention care plan.

Which of the following were in place and being used to prevent falls for this patient/resident? Question Location Event Tab – Additional Questions Section Description Fall prevention protocols or interventions in use at the time of the fall. Prompt Indicate all protocols/interventions which were in use at the time of the fall. Check all that

apply. Responses Alarms (e.g., bed, chair, tab)

Assistive devices (e.g., wheelchair, commode, cane, crutches, scooter, walker) Bed in low position Call light/personal items within reach Change in medication Hip and/or joint protectors Identified as a high fall risk Intentional rounding Non-slip floor mats Non-slip footwear Patient and family education Patient situated close to the nurses' station Physical/occupational therapy (including exercise or mobility program) Siderails or assist rails Sitter Supplemental, environmental or area lighting (when usual facility lighting is considered insufficient) Toileting regimen Visible identification of patient/resident as being at risk for fall (e.g., Falling Star) None Unknown Other (please describe)


Required Yes Question Type Checkboxes Guide for Use Answer this question even if no fall risk assessment was performed prior to the fall. Select


each fall risk protocol/intervention that was being used to prevent falls for the patient who fell. Do not select interventions that, although required or recommended by a care plan or protocol, were not in place or being used at the time of the fall. Please note: not all protocols/interventions in this list are currently considered best practice, and only individuals qualified by the facility may be considered a "sitter" for the purpose of a fall prevention care plan. If a patient, family member or staff has removed an intervention, please consider it “not in use.”

Prior to the fall, what was the patient/resident doing or trying to do? Question Location Event Tab – Additional Questions Section Description Determination of the action the patient/resident was doing or trying to do prior to the fall. Prompt n/a Responses Walking with assistance and/or with an assistive device or medical equipment

Walking without assistance and without an assistive device or medical equipment Changing position (e.g., in bed, chair, etc.) Dressing or undressing Engaging in recreational activities Navigating bedrails/siderails/assist rails Reaching for an item Showering or bathing Toileting-related activities Transferring to or from bed, chair, wheelchair, etc. with assistance Transferring to or from bed, chair, wheelchair, etc. without assistance Sleeping Standing or sitting Wheeling in wheelchair or scooter Unknown Other (please describe)


Required Yes Question Type Select Dropdown Guide for Use For further guidance, please see “What is the correct activity for a fall?” in the FAQ.

What was the patient/resident’s goal? Why did s/he get up or try to get up? Question Location Event Tab – Additional Questions Section Description Determination of the patient’s goal before the fall. Prompt Check all that apply. Responses Relieve hunger or thirst

Adjust controls in the environment (e.g., TV volume, heat) Change location (e.g., move to another room, different chair) Exercise (e.g., PT/OT) Retrieve a personal item (e.g., TV remote, cigarettes, clothing, medication) Return to bed or chair Toileting Unknown Other (please describe)


Required Yes Question Type Checkboxes

https://oregonpatientsafety.org/psrp/docs/PSRP_FAQ.pdf



Was the fall observed? Question Location Event Tab – Additional Questions Section Description Determination on whether the fall was observed. Prompt n/a Responses Yes – by staff (regardless of who else observed the fall)

Yes – by visitor, family or another patient/resident, but not staff No Unknown

Go-To Logic This question only appears if the event type is Fall. Required Yes Question Type Radio Buttons Guide for Use A fall is observed if another person saw the patient/resident reach the ground or other

unintended surface. An assisted fall is inherently an observed fall.

Was the fall assisted or unassisted? Question Location Event Tab – Additional Questions Section Description Determination if the fall was unassisted or assisted Prompt n/a Responses Assisted

Unassisted Unknown

Go-To Logic This question only appears if the event type is Fall. Required Yes Question Type Radio Buttons Guide for Use An assisted fall occurs when the patient/resident begins to fall, is assisted by another person,

but nevertheless reaches the ground or other unintended surface.

Did any physical device contribute to the fall? Question Location Event Tab – Additional Questions Section Description Determination of whether or not a physical device contributed to the fall. Prompt Includes, but is not limited to, assistive devices, restraints, bedrails, and tripping over device

electrical power cords, IV tubes, etc. Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Fall. Required No Question Type Radio Buttons Guide for Use Choose “yes” if assistive devices (e.g. wheelchair, commode, cane, crutches, scooter, walker)

restraints, bedrails or another physical device actively contributed to the fall. Do not choose “yes” if the absence of a physical device contributed to the fall.

What was the physical or environmental cause of the fall? Question Location Event Tab – Additional Questions Section Description Determination of whether or not a physical or environmental factor caused the fall. Prompt Check all that apply Responses Legs or knees “gave out” or stiffened suddenly

Loss of balance or footing Loss of consciousness Patient condition (e.g., TIA, seizure)


Device or equipment (e.g., walker rolled forward, wheelchair footrest broke) Fell out of bed (e.g., rolled out of bed, slipped off a slippery mattress) Slip or trip Tangled in cords, tubing, or similar Unknown Other (please describe)


Required Yes Question Type Checkboxes Guide for Use Physical causes include the individual (e.g., loss of balance, seizures, etc.) whereas

environmental causes include the surrounding environment (e.g., patient was tangled in cords, slipped on wet floor, etc.)

Did the patient/resident sustain a physical injury as a result of the fall? Question Location Event Tab – Additional Questions Section Description Determination if the patient/resident sustained a physical injury as a result of the fall. Prompt n/a Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Fall. If “yes,” opens the question “What type of injury was sustained?”

Required Yes Question Type Radio Buttons Guide for Use No further information provided.

What type of injury was sustained? Question Location Event Tab – Additional Questions Section Description Determination of the type of injury sustained as a result of the fall. Prompt If more than one, choose most severe. Responses Dislocation

Fracture Intracranial injury Laceration requiring sutures Skin tear, avulsion, hematoma or significant bruising Abrasion or laceration not requiring sutures Other (please describe)

Go-To Logic This question only appears if “Did the patient/resident sustain a physical injury as a result of the fall?” was answered “yes.” If “other,” a text box for description will also open.

Required Yes Question Type Select Dropdown Guide for Use If the patient/resident sustained more than one type of injury as a result of the fall, select the

injury which in your judgment caused the greatest harm to the patient/resident. You may wish to refer to Appendix II: Harm Categories and Algorithm in arriving at your determination.

Healthcare-Associated Infection (HAI) Event

Type of healthcare-associated infection (HAI) Question Location Event Tab – Additional Questions Section Description Determination of what type of HAI is being reported.


Prompt Check all that apply. Responses Eye, ear, nose, throat, or mouth infection

Gastrointestinal system infection Lower respiratory tract infection (other than pneumonia) Skin or soft tissue infection Primary blood stream infection (BSI) Central line-associated BSI (CLABSI) Pneumonia Ventilator-associated Pneumonia (VAP) Sepsis Urinary tract infection (UTI) Catheter-associated UTI (CAUTI) Other (please describe)

Go-To Logic This question only appears if the event type is Healthcare-associated infection (HAI). If the type of HAI is Central line associated BSI (CLABSI), opens the question “Type of central line involved.” If “other,” a text box for description will also open.

Required Yes, if event type is Healthcare-associated infection (HAI). Question Type Checkboxes Guide for Use Please see Appendix IV for Healthcare-associated infection event type definitions.

“Aspiration pneumonia” should be submitted as both an Aspiration and Pneumonia (HAI event).

Was the infection determined to be present or incubating on admission? Question Location Event Tab – Additional Questions Section Description Determination if the infection was present or incubating on admission. Prompt n/a Responses No

Yes – infection was related to a previous admission at this facility Yes – infection was determined to be present or incubating on admission Unknown

Go-To Logic This question only appears if the event type is Healthcare-associated infection (HAI). Required Yes, if event type is Healthcare-associated infection (HAI). Question Type Select Dropdown Guide for Use Select the most appropriate “Yes” response if the professional(s) responsible for making this

determination at your facility have determined that the infection you are reporting was present or incubating on admission. Select “No” if the determination was that the infection developed during the admission. If no conclusive determination has been made, or you do not know what the determination is, select “Unknown”.

Type of pathogen Question Location Event Tab – Additional Questions Section Description Determination of pathogen involved in HAI event. Prompt n/a Responses C. diff (Clostridium difficile)

CRE (Carbapenem-Resistant Enterobacteriaceae) E. coli (Escherichia coli) Fungal (including candida) MRSA (Methicillin-resistant Staphylococcus aureus) MSSA (Methicillin-sensitive Staphylococcus aureus) Other Staph aureus


VRE (Vancomycin-resistant Enterococci) Other Unknown

Go-To Logic This question only appears if the event type is Healthcare-associated infection (HAI). Required No Question Type Select Dropdown Guide for Use Pathogen type must be verified by a culture. If a positive culture was not obtained, select

“unknown.”

Type of central line involved Question Location Event Tab – Additional Questions Section Description Determination of the type of central line involved in the central line-associated bloodstream

infection. Prompt n/a Responses Permanent/long-term (tunneled or implanted) central line

Temporary (non-tunneled or PICC) central line Unknown

Go-To Logic This question only appears if the type of HAI is Central line associated BSI (CLABSI). Required Yes Question Type Select Dropdown Guide for Use A “permanent central line” is a central line that is tunneled, including certain dialysis

catheters and implantable central line catheters (including ports). A “temporary central line” is a central line that is not tunneled, including PICC lines.


Medication or Other Substance Event

Type of medication or other substance event Question Location Event Tab – Additional Questions Section Description Determination of the type of medication or other substance event. Prompt Check all that apply. Responses Incorrect medication or substance

Incorrect route Incorrect dosage form Incorrect strength Incorrect dose Incorrect rate Incorrect time Expired medication or substance Incorrect/incomplete labeling Medication or substance contraindicated (includes documented allergies and sensitivities) Medication or substance discontinued Medication or substance omitted Allergic reaction due to unknown allergy Adverse reaction not due to allergy or known contraindication Drug interaction Oversedation Other (please describe)

Go-To Logic This question only appears if the event type is Medication or other substance. If “other,” a text box for description will also open.

Required Yes, if event type is Medication or other substance. Question Type Checkboxes Guide for Use Please see Appendix V: Medication or Other Substance Event Type Descriptions for definitions

and common inclusions and exclusions. You may also want to refer to the PSRP Corner article on this topic (https://oregonpatientsafety.org/blog/blog/how-do-i-classify-my-medication-related-adverse-event/735/). In keeping with NQF, hypoglycemia is considered a harm resulting from a medication event.

What type of medication/substance was involved? Question Location Event Tab – Additional Questions Section Description Determination of the type of medication/substance involved in the event. Prompt Check all that apply. Responses Prescription or over-the-counter (including herbal supplements)

Compounded preparation Other substance Unknown

Go-To Logic This question only appears if the event type is Medication or other substance. If “Other substance,” opens the question “Type of other substance.”

Required No Question Type Select Dropdown Guide for Use A medication is a type of drug.

Prescription or over-the-counter medications are available commercially in final form. This includes products containing chlorhexidine gluconate (CHG). Compounded preparations require the intercession of an authorized compounder and are not available off the shelf. They are prepared by mixing two or more drugs or compounds, thus the name. Other substance includes biological products (e.g. vaccines, thrombolytics); nutritional

https://oregonpatientsafety.org/blog/blog/how-do-i-classify-my-medication-related-adverse-event/735/

https://oregonpatientsafety.org/blog/blog/how-do-i-classify-my-medication-related-adverse-event/735/


products (e.g. dietary supplements; vitamins or minerals; enteral nutritional products, including infant formula; parenteral nutritional products); patient/resident food.

Type of other substance Question Location Event Tab – Additional Questions Section Description Determination of the type of medication/substance involved in the event. Prompt n/a Responses Biological products (including vaccines)

Nutritional products Patient/resident food Other (please describe)

Go-To Logic This question only appears if “What type of medication/substance was involved?” was answered “Other substance.” If “other,” a text box for description will also open.

Required No Question Type Select Dropdown Guide for Use A biological product means any virus, therapeutic serum, toxin, antitoxin, or analogous

product applicable to the prevention, treatment or cure of disease or injury. A nutritional product, for the purposes of this form, does not include "conventional" food(e.g. dietary supplements; vitamins or minerals; enteral nutritional products, including infant formula; parenteral nutritional products).

Generic name or investigational drug name Question Location Event Tab – Additional Questions Section Description Identification of the generic name or investigational drug name of the product involved in the

event. Prompt n/a Go-To Logic This question only appears if the event type is Medication or other substance. Required No Question Type Text Input

There are five rows available for up to 5 medications or other substances that may have been involved in this event.


Was this medication/substance prescribed for this patient? Question Location Event Tab – Additional Questions Section Description Determination of the medication/substance prescribed for this patient/resident. Prompt n/a Responses Yes

No Go-To Logic This question only appears if the event type is Medication or other substance. Required No Question Type Radio Buttons


Guide for Use Do not include information about compounded preparations or expressed breast milk when responding.

Was this medication/substance given to this patient? Question Location Event Tab – Additional Questions Section Description Determination if the medication/substance was given to this patient/resident. Prompt n/a


Responses Yes No

Go-To Logic This question only appears if the event type is Medication or other substance. Required No Question Type Radio Buttons


Guide for Use Do not include information about compounded preparations or expressed breast milk when responding.

At what stage in the process did the event originate, regardless of the stage at which it was discovered? Question Location Event Tab – Additional Questions Section Description The stage in the process the event originated. Prompt n/a Responses Purchasing

Storing Prescribing/ordering Transcribing Preparing Dispensing (includes labeling) Administering Monitoring Unknown Other (please describe)

Go-To Logic This question only appears if the event type is Medication or other substance. If “other,” a text box for description will also open.

Required No Question Type Select Dropdown Guide for Use Purchasing includes purchasing for stock or for a particular patient/resident.

Storing includes maintaining the substance under special environmental conditions and in accordance with appropriate security requirements. Prescribing/ordering means the issuance of an order by an authorized professional for the delivery or administration of a substance to a patient/resident. This may be done in writing, verbally or through an electronic order entry system. Transcribing includes documenting verbal orders in writing or electronically, entering written orders into an electronic system and copying orders for separate uses. Preparing includes taking substances from stock, manipulating them, compounding, and measuring and apportioning doses, such as the filling of cartridges and unit-dose syringes. Dispensing includes assuring accurate labeling of the prepared substance, issuance of the substance from the pharmacy, and delivery by pharmacy personnel to the patient/resident care area. Administering generally occurs in a patient/resident care area and includes checking orders and patient/resident identity and delivering the substance to the patient/resident either by oral ingestion or by direct application (e.g., injection, insertion, or topical application) or with the use of indwelling lines, tubes or catheters. Monitoring includes measuring and observing to determine the presence or absence of the desired effect of the substance administered and to detect any unintended adverse effects. If a Medication or substance discontinued event occurs because the pharmacy makes the error, it originated at dispensing. If the order is missed, it originated at prescribing. Otherwise, a discontinuation originates at administration. If an extra dose of medication is given, the event originates in administration.


If the nurse did not write the telephone order correctly, the event originates in transcription. Manufacturer labeling errors originate at other. If an error occurs in the room of a patient/resident who is independent with medication administration because of inadequate instruction to the patient/resident, the event originates at administering.

Were any of the following involved? Question Location Event Tab – Additional Questions Section Description Additional medication event-specific contributing factors. Prompt Check all that apply. Responses Look-alike/sound-alike drugs

Two or more prescriptions filled at the same time Medications administered to two or more patient/residents at the same time New prescription Refill prescription

Go-To Logic This question only appears if the event type is Medication or other substance. Required No Question Type Checkboxes Guide for Use No further information provided.

What was the contraindication (potential or actual interaction)? Question Location Event Tab – Additional Questions Section Description The determination of a contraindication (potential or actual interaction) to the administration

of a medication or substance to which a patient/resident was known to have allergies or sensitivities.

Prompt n/a Responses Documented allergy or sensitivity

Drug-drug Drug-food Drug-disease Other contraindication (please describe)

Go-To Logic This question only appears if the type of “Type of medication or other substance event” is “Medication or substance contraindicated (includes documented allergies and sensitivities).” If “other,” a text box for description will also open.

Required No Question Type Select dropdown Guide for Use No further information provided.

What was the intended route of administration? Question Location Event Tab – Additional Questions Section Description Determination of the intended route of administration. Prompt n/a Responses Cutaneous, topical application, including ointment, spray, patch

Subcutaneous Ophthalmic Oral, including sublingual or buccal Otic Nasal Inhalation Intravenous Intramuscular Rectal


Vaginal Unknown Other (please describe below)

Go-To Logic This question only appears if the type of “Type of medication or other substance event” is “Incorrect route.” If “other,” a text box for description will also open.


What was the actual route of administration? Question Location Event Tab – Additional Questions Section Description The actual route of administration if the event involved an incorrect route of administration. Prompt Includes attempted and completed. Responses Cutaneous, topical application, including ointment, spray, patch

Subcutaneous Ophthalmic Oral, including sublingual or buccal Otic Nasal Inhalation Intravenous Intramuscular Rectal Vaginal Unknown Other (please describe below)

Go-To Logic This question only appears if the type of “Type of medication or other substance event” is “Incorrect route.” If “other,” a text box for description will also open.



Pressure Ulcer Event

Most advanced stage of pressure ulcer being reported Question Location Event Tab – Additional Questions Section Description Determination of the most advanced stage of the pressure ulcer or suspected deep tissue

injury being reported. Prompt n/a Responses Stage 1

Stage 2 Stage 3 Stage 4 Unstageable Suspected deep tissue injury Unknown

Go-To Logic This question only appears if the event type is Pressure ulcer. Required No Question Type Select Dropdown Guide for Use Note: Pressure ulcers Stage III and above are always permanent harm.

Select Stage 1 if the most advanced stage of the skin lesion being reported was intact skin with non-blanchable redness of a localized area usually over a bony prominence. Select Stage 2 if the most advanced stage of the skin lesion being reported was partial-thickness tissue loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Select Stage 3 if the most advanced stage of the skin lesion being reported was full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Select Stage 4 if the most advanced stage of the skin lesion being reported was full-thickness tissue loss with exposed bone, tendon or muscle. Select Unstageable if the most advanced stage of the skin lesion being reported was full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Select Suspected Deep Tissue Injury if the most advanced stage of the skin lesion being reported was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

What was the stage of the pressure ulcer on admission? Question Location Event Tab – Additional Questions Section Description Determination of the status of the existing pressure ulcer on admission to the facility. Prompt n/a Responses Not present

Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Suspected deep tissue injury Unknown

Go-To Logic This question only appears if the event type is Pressure ulcer. Required No Question Type Select Dropdown Guide for Use Select Stage 1 if, on admission, the stage of the skin lesion being reported was intact skin with

non-blanchable redness of a localized area usually over a bony prominence. Select Stage 2 if, on admission, the stage of the skin lesion being reported was partial-


thickness tissue loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Select Stage 3 if, on admission, the stage of the skin lesion being reported was full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Select Stage 4 if, on admission, the stage of the skin lesion being reported was full-thickness tissue loss with exposed bone, tendon or muscle. Select Unstageable if, on admission, the stage of the skin lesion being reported was full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Select Suspected Deep Tissue Injury if, on admission, the stage of the skin lesion being reported was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Pressure ulcer location on the body Question Location Event Tab – Additional Questions Section Description Location of the pressure ulcer on the body. Prompt Check all that apply to the specific ulcer being reported. Responses Ankle

Back Back of head Buttock Coccyx Elbow Heel Hip Knee Sacrum Shoulder Thigh Other (please describe)

Go-To Logic This question only appears if the event type is Pressure ulcer. If “other,” a text box for description will also open.

Required No Question Type Checkboxes Guide for Use No further information provided.

On admission to the facility, was a skin inspection documented? Question Location Event Tab – Additional Questions Section Description Documentation of a skin inspection done on admission to this facility. Prompt Check one. Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Pressure ulcer. Required No Question Type Radio Buttons Guide for Use Select Yes if a skin inspection was documented on admission to the facility in accordance with

facility’s internal Policies & Procedures. Select No if there was no documentation of an admission skin inspection performed in accordance with the facility's internal Policies & Procedures.


When was the first pressure ulcer risk assessment documented? Question Location Event Tab – Additional Questions Section Description Determination of when the first pressure ulcer risk assessment was performed Prompt n/a Responses On admission (within 24 hours)

Not on admission, but documented prior to the discovery of a newly-developed, or advancement of an existing, pressure ulcer Not on admission, but documented after discovery of a newly-developed, or advancement of an existing, pressure ulcer No risk assessment documented Unknown

Go-To Logic This question only appears if the event type is Pressure ulcer. If “On admission (within 24 hours) or “Not on admission, but documented prior to the discovery of a newly-developed, or advancement of an existing, pressure ulcer,” opens the questions “Type of risk assessment performed” and “Was the patient/resident assessed to be at any level of risk for a pressure ulcer?”

Required No Question Type Radio Buttons Guide for Use No further information provided.

Type of risk assessment performed Question Location Event Tab – Additional Questions Section Description Determination of the type of risk assessment used. Prompt n/a Responses Clinical assessment

Braden/Braden Q Other formal assessment tool Unknown

Go-To Logic This question only appears if “When was the first pressure ulcer risk assessment documented?” was answered “On admission (within 24 hours) or “Not on admission, but documented prior to the discovery of a newly-developed, or advancement of an existing, pressure ulcer.”

Required No Question Type Select Dropdown Guide for Use Answer this question only if a pressure ulcer risk assessment was performed prior to the

discovery of a new, or the advancement of an existing, pressure ulcer or suspected deep tissue Injury. Select Clinical assessment if the type of risk assessment performed was based on a clinical evaluation but was not based on a published formal scale or score. Select Other formal assessment tool if the type of risk assessment performed was a formal assessment, such as one involving a score or scale that has been published, tested and validated but was not the Braden/Braden Q (e.g., Norton, Waterlow, etc.).

Was the patient/resident assessed to be at any level of risk for a pressure ulcer? Question Location Event Tab – Additional Questions Section Description Determination if the patient/resident was documented to be at increased risk for pressure

ulcer as a result of the risk assessment. Prompt n/a Responses Yes

No Unknown

Go-To Logic This question only appears if “When was the first pressure ulcer risk assessment


documented?” was answered “On admission (within 24 hours) or “Not on admission, but documented prior to the discovery of a newly-developed, or advancement of an existing, pressure ulcer.”

Required No Question Type Select Dropdown Guide for Use Answer this question only if a pressure ulcer risk assessment was performed prior to the

discovery of a new, or the advancement of an existing, pressure ulcer or suspected deep tissue Injury.

Was any preventive intervention implemented? Question Location Event Tab – Additional Questions Section Description Determination if a prevention intervention was implemented, and if so, of the type of

prevention intervention(s). Prompt Check all that apply. Responses Pressure redistribution device

Repositioning Hydration and/or nutritional support Skin care practices to prevent moisture and shearing None Unknown Other (please describe)

Go-To Logic This question only appears if the event type is Pressure ulcer. If “other,” a text box for description will also open.

Required No Question Type Select Dropdown Guide for Use Answer this question only if an intervention to prevent the development or advancement of

pressure ulcers had been implemented for the patient/resident.

Was the use of a device or appliance involved in the development or advancement of the pressure ulcer? Question Location Event Tab – Additional Questions Section Description Determination whether the device or appliance was involved in the development or

advancement of the pressure ulcer. Prompt n/a Responses Yes

No Unknown

Go-To Logic This question only appears if the event type is Pressure ulcer. If “yes”, opens the question “What was the type of device or appliance?”

Required No Question Type Select Dropdown Guide for Use No further information provided.

What was the type of device or appliance? Question Location Event Tab – Additional Questions Section Description The device or appliance used that was associated with the pressure ulcer. Prompt Check all that apply Responses Anti-embolic device (e.g., compression stockings)

Orthopedic appliance (e.g., cast, splint, orthotic) Oxygen delivery device (e.g., nasal prongs, oxygen mask) Positioning device (e.g., lap buddy, wedge cushion) Restraints


Tube (includes endotracheal, gastrostomy, nasogastric, tracheostomy and indwelling urinary catheter) Other (please describe)

Go-To Logic This question only appears if “Was the use of a device or appliance involved in the development or advancement of the pressure ulcer?” was answered “yes.” If “other,” a text box for description will also open.

Required No Question Type Checkboxes Guide for Use Answer this question only if a device or appliance contributed to the development or

advancement of the pressure ulcer.


Appendix I: List of Facilities and Nursing Facility Corporations

Corporation Nursing Facility Avamere Avamere at Three Fountains Avamere Avamere Court at Keizer Avamere Avamere Crestview of Portland Avamere Avamere Health Services of Rogue Valley Avamere Avamere Rehabilitation of Beaverton Avamere Avamere Rehabilitation of Clackamas Avamere Avamere Rehabilitation of Coos Bay Avamere Avamere Rehabilitation of Eugene Avamere Avamere Rehabilitation of Hillsboro Avamere Avamere Rehabilitation of Junction City Avamere Avamere Rehabilitation of King City Avamere Avamere Rehabilitation of Lebanon Avamere Avamere Rehabilitation of Newport Avamere Avamere Rehabilitation of Oregon City Avamere Avamere Riverpark of Eugene Avamere Avamere Twin Oaks of Sweet Home Avamere Bend Transitional Care Avamere Pearl at Kruse Way Avamere Salem Transitional Care Dakavia Fernhill Estates Dakavia Myrtle Point Care Center Dakavia Pacific Health & Rehabilitation Dakavia Sheridan Care Center Extendicare Care Center East Health & Specialty Care Center Extendicare Meadow Park Health & Specialty Care Center Good Samaritan Society Good Samaritan Society - Curry Village Good Samaritan Society Good Samaritan Society - Eugene Village Good Samaritan Society Good Samaritan Society - Fairlawn Village Lake Health District Lakeview Gardens Life Care Centers of America Dallas Retirement Village Health Center Life Care Centers of America Valley West Health Care Center Marquis Companies Marquis Autumn Hills Memory Care Marquis Companies Marquis Centennial Post Acute Rehab Marquis Companies Marquis Forest Grove Post Acute Rehab Marquis Companies Marquis Hope Village Marquis Companies Marquis Mill Park Marquis Companies Marquis Mt. Tabor Marquis Companies Marquis Newberg Marquis Companies Marquis Oregon City Post Acute Rehab Marquis Companies Marquis Piedmont Post Acute Rehab Marquis Companies Marquis Plum Ridge Marquis Companies Marquis Silver Gardens Marquis Companies Marquis Springfield Marquis Companies Marquis Tualatin Post Acute Rehab Marquis Companies Marquis Vermont Hills Marquis Companies Marquis Wilsonville Post Acute Rehab Pacific Retirement Services Cascade Manor Pacific Retirement Services Holladay Park Plaza


Corporation Nursing Facility Pacific Retirement Services Rogue Valley Manor Health Center Pinnacle Corvallis Manor Nursing & Rehabilitation Center Pinnacle French Prairie Nursing & Rehabilitation Center Pinnacle Green Valley Rehabilitation Health Center Pinnacle Hearthstone Nursing and Rehabilitation Center Pinnacle Highland House Nursing & Rehabilitation Center Pinnacle Hillside Heights Rehabilitation Center Pinnacle Rose Haven Nursing Center Pinnacle Royale Gardens Health & Rehabilitation Center Pinnacle South Hills Rehabilitation Center Pinnacle Umpqua Valley Nursing & Rehabilitation Center Prestige Cascade Terrace Nursing Center Prestige Chehalem Health & Rehab Center Prestige Coast Fork Nursing Center Prestige Creswell Health and Rehabilitation Center Prestige Forest Grove Rehabilitation and Care Center Prestige Glisan Care Center Prestige Hood River Care Center Prestige Linda Vista Nursing & Rehab Center Prestige Molalla Manor Care Center Prestige Oregon City Health Care Center Prestige Park Forest Care Center Prestige Porthaven Healthcare Center Prestige Prestige Care and Rehabilitation of Menlo Park Prestige Prestige Care and Rehabilitation of Reedwood Prestige Prestige Post-Acute and Rehabilitation Center -

Gresham Prestige Prestige Post-Acute and Rehabilitation Center -

Oakwood Prestige Timberview Care Center Prestige Willowbrook Terrace Prestige Prestige Post-Acute and Rehabilitation Center -

Milwaukie Providence Health & Services Providence Benedictine Nursing Center Providence Health & Services Providence Child Center Regency Pacific Cascade View Nursing Center Regency Pacific Regency Care of Rogue Valley Regency Pacific Laurel Hill Nursing & Rehab Center Regency Pacific Ochoco Care Center Regency Pacific Pilot Butte Rehab Center Regency Pacific Regency Redmond Rehabilitation and Nursing Center Regency Pacific Regency Albany Regency Pacific Regency Florence Regency Pacific Regency Gresham Nursing & Rehabilitation Center Regency Pacific Regency Hermiston Nursing & Rehabilitation Center Regency Pacific Regency Prineville Rehabilitation and Care Center Independent Aidan Senior Living at Reedsport Independent Blue Mountain Care Center Independent Clatsop Care Health & Rehabilitation Center Independent Columbia Basin Care Facility


Corporation Nursing Facility Independent Columbia Care Center Independent Cornerstone Care Option Independent Friendship Health Center Independent Gracelen Terrace Long Term Care Facility Independent Healthcare at Foster Creek Independent Lawrence Convalescent Center Independent Marian Estates Independent Mary's Woods at Marylhurst Independent Maryville Nursing Facility Independent Nehalem Valley Care Center Independent Oregon Veterans’ Home Independent Presbyterian Community Care Center Independent Robison Jewish Health Center Independent Rose City Nursing Facility Independent Rose Linn Care Center Independent Rose Villa Senior Living Independent Sherwood Park Nursing & Rehab Center Independent Town Center Village Rehab Independent Village Health Care Independent West Hills Health & Rehabilitation Center Independent Willamette View Health Center

Appendix II: Harm Categories and Algorithm

Harm Categories

Category A Circumstances that have the capacity to cause an adverse event No adverse event

Category B An event occurred that did not reach the patient (an “error of omission”

does reach the patient)

Adverse event,

no harm

Category C An event occurred that reached the patient but did not cause patient harm

Category D An event occurred that reached the patient and required monitoring to

confirm that it resulted in no harm to the patient and/or required

intervention to preclude harm

Category E An event occurred that may have contributed to or resulted in temporary

harm to the patient but did not require a significant intervention

Adverse event,

harm

Category F An event occurred that may have contributed to or resulted in temporary

harm to the patient and required a significant intervention

Category G An event occurred that may have contributed to or resulted in permanent

patient harm

Category H An event occurred that required intervention necessary to sustain life

Category I An event occurred that may have contributed to or resulted in patient’s

death

Adverse event,

death

Adapted from “NCC MERP Index for Categorizing Medication Errors.”

2001 National Coordinating council for Medication Error Reporting and Prevention.

Definitions

Adverse Event An event resulting in unintended harm or creating the potential for harm that is related to any aspect of a patient’s care (by an act of commission or omission) rather than to the underlying disease or condition of the patient; adverse events may or may not be preventable

Harm Any physical injury or damage to the health of a person and/or pain resulting therefrom, including both temporary and permanent injury

Permanent Harm Harm lasting more than six months or where the end harm is not known

Monitoring To observe or record physiological or psychological signs

Intervention May include change in therapy or active medical/surgical treatment

Intervention Necessary to Sustain Life Includes cardiovascular and/or respiratory support (e.g., CPR, defibrillation, intubation)

Significant Intervention An intervention intended to relieve symptoms that have the potential to be life-threatening if not addressed.


Category F

Did an actual adverse

event occur?

Circumstances that have

the capacity to cause an

adverse event

Category A

Did the event reach

the patient?

(An error of omission

does reach the patient)

Did the event

contribute to or result

in patient death?

Category I

Yes

No

No

No

Yes

Yes

Category B

Was the patient

harmed?

Category C

Was extra monitoring or

an intervention to

preclude harm

required?

Was an intervention

necessary to sustain life

required?

Was the harm

permanent?

Category H

Was the harm

temporary?

Category G

Category E

No

No

No

Yes

No

Yes

Yes

Yes

Yes

No

Category D

Did the event

require a significant

intervention?

No

Adapted from “NCC MERP Index for Categorizing Medication Errors Algorithm.”

2001 National Coordinating council for Medication Error Reporting and Prevention.

Harm Algorithm Definitions

Adverse Event

An event resulting in unintended harm or creating the potential for

harm that is related to any aspect of a patient’s care (by an act of

commission or omission) rather than to the underlying disease or

condition of the patient; adverse events may or may not be

preventable

Harm

Any physical injury or damage to the health of a person and/or pain

resulting therefrom, including both temporary and permanent injury

Permanent Harm

Harm lasting more than six months or where the end harm is not

known

Monitoring

To observe or record physiological or psychological signs

Intervention

May include change in therapy or active medical/surgical treatment

Intervention Necessary to Sustain Life

Includes cardiovascular and/or respiratory support (e.g., CPR,

defibrillation, intubation)

Significant Intervention

An intervention intended to relieve symptoms that have the potential

to be life-threatening if not addressed

Appendix III: Event Type Descriptions A brief definition for each event type is provided below. If pertinent, common inclusions (“INCLUDES”), common

exclusions (‘EXCLUDES”), and a note about specific instances that should be submitted as two different event types

(“NOTE”) are also provided. The lists of inclusions and exclusions are not exhaustive; if you have additional

questions, please contact your Patient safety Consultant.

Event type Definition

Aspiration Patient/resident death or serious injury associated with an aspiration.

INCLUDES: aspiration pneumonia (submit as both Aspiration and Healthcare-associated infection events)

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 (submit as Device or supply (including use error))

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

Choking Patient/resident death or serious injury associated with choking.

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 stage 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 stage 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 resident, and fluctuates as the resident’s condition fluctuates (e.g., increase fluids



if resident has fever or diarrhea).

Device or supply (including use error)

Patient/resident death or serious injury associated with the use or function of a device or supply, including disposable products, 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; latex gloves used for a procedure on a latex allergic patient/resident

Diabetic coma Patient/resident death or serious injury associated with a diabetic coma.

INCLUDES: diabetic coma related to hypoglycemia or hyperglycemia

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

Elopement Patient/resident death or serious injury associated with patient/resident 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/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., 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/resident falls or drops from equipment (e.g., bed, lift)

EXCLUDES: falls associated with suicide or attempted suicide

Note: you may want to refer to the PSRP Corner article on this topic (https://oregonpatientsafety.org/blog/blog/how-should-i-define-a-fall/687/)

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 associated with 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, (e.g. eye, ear, nose, throat, and mouth infections; gastrointestinal system infections; lower respiratory tract infections (including pneumonia and ventilator-associated pneumonia (VAP)); skin or soft tissue infections; primary blood stream infections (including central line associated blood stream infections (CLABSI)); sepsis; urinary tract infection (UTI) (including catheter-associated urinary tract infection (CAUTI))

EXCLUDES: infections present or incubating on admission that are assessed and treated appropriately

Intravascular embolisms related to IV therapy

Patient/resident death or serious injury associated with intravascular air embolism

https://oregonpatientsafety.org/blog/blog/how-should-i-define-a-fall/687/



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 cared for in your facility

Medication or other substance

Patient/resident death or serious injury associated with a medication or other substance.

INCLUDES: hypoglycemia; incorrect medication or substance; incorrect dose; incorrect patient/resident; 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; oversedation

EXCLUDES: reasonable differences in clinical judgment on drug selection and dose

Pressure ulcer (also means pressure injury)

Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission, or that were present on admission and fails to show some evidence of progress toward stabilization or healing within 2-4 weeks.

INCLUDES: Stage 3 or 4 pressure ulcers, or pressure ulcers 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 ulcers that develop in areas where deep tissue injury is documented as present on admission/presentation; development of a pressure ulcer in a patient/resident who’s clinical condition demonstrates that it was unavoidable; failure of a pressure ulcer 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.

“Unavoidable” means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

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 facility to the hospital) (submit as Other event)

Restraint or bed rail related

Patient/resident death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare facility.

INCLUDES: entrapment

EXCLUDES: suicide (submit as 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 (submit as Restraint or bed rail related); suicide (submit as 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 the facility

EXCLUDES: deaths resulting from self-inflicted injuries that were the reason for admission to the facility

Other 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; events that are NOT related to the natural course of the patient/resident’s illness or underlying condition; injuries not related to another event; thromboembolism; events related to poor discharge planning or inadequate patient/resident assessment; premature pronouncement of death; 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/resident’s illness or underlying condition; injuries related to another event


Appendix IV: Healthcare-Associated Infection Event Type Descriptions


Eye, ear, nose, throat, or mouth infection

Patient/resident death or serious injury related to a healthcare-associated eye, ear, nose, throat, or mouth infection.

Gastrointestinal system infection

Patient/resident death or serious injury related to a healthcare-associated gastrointestinal system infection.

INCLUDES: C. diff infections (select “C. difficile” as the Pathogen)

Lower respiratory tract infection (other than pneumonia)

Patient/resident death or serious injury related to a healthcare-associated lower respiratory tract infection (other than pneumonia)

EXCLUDES: pneumonias (submit as Pneumonia)

Skin or soft tissue infection

Patient/resident death or serious injury related to a healthcare-associated skin or soft tissue infection.

INCLUDES: yeast infections

Primary blood stream infection (BSI)

Patient/resident death or serious injury related to a healthcare-associated primary blood stream infection

Central line associated BSI (CLABSI)

Patient/resident death or serious injury related to a healthcare-associated central line associated primary blood stream infection.

A catheter-associated bloodstream infection (CLABSI) is a primary bloodstream infection (BSI) in a patient/resident that had a central line within the 48-hour period before the development of the BSI and that is not related to an infection at another site. NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated.

Pneumonia Patient/resident death or serious injury related to healthcare-associated pneumonia.

INCLUDES: aspiration pneumonia (submit as both Aspiration and Healthcare-associated infection events)

Ventilator-associated Pneumonia (VAP)

Patient/resident death or serious injury related to healthcare-associated ventilator-associated pneumonia.

A ventilator-associated pneumonia (VAP) is pneumonia that occurs in a patient/resident who was intubated and ventilated at the time of, or within 48 hours before, the onset of the pneumonia.

EXCLUDES: patient/residents with a diagnosis of pneumonia on admission

Sepsis Patient/resident death or serious injury related to healthcare-associated sepsis.

Urinary tract infection (UTI)

Patient/resident death or serious injury related to healthcare-associated urinary tract infection.

Catheter-associated UTI (CAUTI)

Patient/resident death or serious injury related to healthcare-associated catheter-associated urinary tract infection.

A catheter-associated urinary tract infection (CAUTI) is a urinary tract infection (UTI) that occurs in a patient/resident who had an indwelling urinary catheter in place within the 48-hour period before the onset of the UTI.

Other Patient/resident death or serious injury related to a healthcare-associated infection not otherwise included in the above categories.

INCLUDES: facial cellulitis


Appendix V: Medication or Other Substance Event Type Descriptions


Incorrect medication or substance

Patient/resident death or serious injury associated with being given a medication or other substance that was not ordered for him or her, or was intended for another patient/resident.

INCLUDES: medications intended for another patient/resident; medication or other substance that was not ordered for patient/resident

EXCLUDES: medication not appropriate to the patient/resident’s clinical situation (e.g., giving a patient/resident with a drug resistant infection a drug in the family to which the infection is resistant) (submit as Medication or other substance contraindicated)

Incorrect route Patient/resident death or serious injury associated with being given a medication or other substance through the incorrect route of administration.

INCLUDES: injection of medication or substance given instead of medication or substance being used for irrigation; giving IM dose titrated through IV; suspension medication given through PICC instead of PEG; giving a suppository instead of tablet; giving a patch instead of an IV

Incorrect dosage form Patient/resident death or serious injury associated with being given a medication or other substance in the incorrect dosage form.

INCLUDES: sustained release instead of immediate release; giving tablet instead of liquid form

Incorrect strength Patient/resident death or serious injury associated with being given a medication or other substance in the incorrect strength/concentration.

INCLUDES: concentrations that are too high or too low; patient/resident is given an “unmixed” antibiotic that was supposed to mixed with another substance; patches

applied that are the incorrect concentration (e.g., Fentynl patch 25gm instead of

50gm)

Incorrect dose Patient/resident death or serious injury associated with being given a medication or other substance in the incorrect dose (i.e., too much or too little).

INCLUDES: giving too much or too little of a medication or other substance at once; overdose; underdose; extra dose

EXCLUDES: omitted medication (submit as Medication or substance omitted); incorrectly discontinued medication (submit as Medication or substance discontinued); IV medications given at an incorrect rate (submit as Incorrect rate)

Incorrect rate Patient/resident death or serious injury associated with being given a medication or other substance at the incorrect rate.

INCLUDES: giving too much or too little of an IV medication or other substance over time

Incorrect time Patient/resident death or serious injury associated with being given a medication or other substance at the incorrect time (i.e., too early or too late).

INCLUDES: patient was given ordered medication too early or too late; given an ordered medication outside of the time parameters indicated by the prescription; ordering a medication late resulting in late administration

Expired medication or substance

Patient/resident death or serious injury associated with being given a medication or other substance whose expiration date has passed.

INCLUDES: giving medications or other substances whose expiration date has passed



Incorrect/incomplete labeling

Patient/resident death or serious injury associated with being given a medication or other substance with incorrect or incomplete labeling.

INCLUDES: medication hung and infused but not labeled or documented

Medication or substance contraindicated (includes documented allergies and sensitivities)

Patient/resident death or serious injury associated with being given a medication or other substance they should not have been given for a known, documented reason.

INCLUDES: patient/resident given a medication or other substance, or a prescription for a medication or other substance, they should not have been given for a documented reason regardless of result; drug-drug contraindication; drug-food contraindication; drug-disease contraindication; drug-clinical condition contraindication

Medication or substance discontinued

Patient/resident death or serious injury associated with the incorrect discontinuation of a medication or other substance without an order.

INCLUDES: ordered medication or substance discontinued without order; O2 discontinued without order

Medication or substance omitted

Patient/resident death or serious injury associated with not being given a medication or other substance that they should have received.

INCLUDES: prescribed medication not given for any reason, including incomplete medication reconciliation at intake or discharge and failure to process/enter medication reconciliation form; giving air instead of injectable medication or substance; ordering a medication late that is not administered to the patient

EXCLUDES: medications that have been incorrectly discontinued (submit as Medication or substance discontinued)

Adverse reaction not due to allergy or known contraindication

Patient/resident death or serious injury associated with being given a medication or other substance (at normal dosage during normal use) for which an adverse reaction occurred that was not due to an allergy or known contraindication.

INCLUDES: anticholinergic reaction syndrome as a result of medication administration; severe hypotensive event as a result of medication administration; other reactions that cannot be classified as an allergic reaction

EXCLUDES: unanticipated allergic reactions (submit as Allergic reaction) or documented allergies or sensitivities (submit as Medication or other substance contraindicated); oversedation (submit as Oversedation)

Allergic reaction due to unknown allergy

Patient/resident death or serious injury associated with being given a medication or other substance for which an unanticipated allergic reaction occurred either in the facility or at home and reported to facility post-discharge.

INCLUDES: an inappropriate immune response, such as a rash or hives, as a result of medication administration; anaphylaxis as a result of medication administration

EXCLUDES: allergic reactions due to documented allergies (choose Medication or substance contraindicated)

Drug interaction Patient/resident death or serious injury associated with an unanticipated drug interaction.

INCLUDES: ordered medications interacting with recreational drugs

EXCLUDES: drug interactions due to contraindications

Oversedation Patient death or serious injury associated with one or more medications that result in a level of sedation greater than the desired therapeutic level of sedation.

INCLUDES: oversedation associated with medications



Other Patient/resident death or serious injury associated with being given a medication or other substance not otherwise included in the above categories.

INCLUDES: patient/resident non-compliant with medication discontinuation instructions; incorrect prescription for patient/resident; transcription error on medication order; incorrect preparation (including inappropriate cutting of tablets, error in mixing, etc.); incorrect patient/resident/family action (e.g. self-administration error)


Appendix VI: Contributing Factor Descriptions

Communication Communication factors may be related to any spoken or written communication between anyone in a

facility, including, but not limited to, providers, staff, patients, and patient families. Ineffective

communication is communication that was inaccurate, incomplete, ambiguous, misunderstood by the

recipient, or not timely.

Factor Definition

Across units Ineffective communication between representatives of different units or departments in a facility contributed to the event.

INCLUDES: one or more units within a facility; misinterpreted communication; incomplete, not timely, inaccurate communication

EXCLUDES: communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams"); communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”); communication between units at different facilities in the same healthcare system (select “With other organizations or outside providers”)

Among interdisciplinary teams Ineffective communication among any group of healthcare professionals from diverse fields who work to coordinate the care of a patient in a facility contributed to the event.

INCLUDES: healthcare professionals in different disciplines working within a designated team or service (e.g., Rapid Response, Code Blue, Infection Prevention)

EXCLUDES: communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”); communication between unit staff and supervisor or manager (select “Between supervisor and staff”)

Between supervisor and staff Ineffective communication between supervisor and staff in a facility contributed to the event.

INCLUDES: misinterpreted communication; incomplete, not timely, inaccurate communication

EXCLUDES: communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”); communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

Handoffs, handovers or shift reports Ineffective communication related to handoffs, handovers or shift reports in a facility or between facilities contributed to the event.

INCLUDES: all healthcare professionals; misinterpreted communication;

incomplete, not timely, inaccurate communication; transfers of patients from one facility to another (also select “With other organizations or outside providers”)

EXCLUDES: communication between unit staff and supervisor or manager (select “Between supervisor and staff”); communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)


Factor Definition

Hard to read fax or handwriting Hard to read handwriting or a hard to read fax contributed to the event.

INCLUDES: illegible printing or handwriting; printing too light to read clearly; a healthcare professional’s temporary notes to self

Within units Ineffective communication within a unit in a facility contributed to the event.

EXCLUDES: across staff on multiple units (select “Across units”); communication related to handoffs, handovers or shift reports (select “Handoffs, handovers or shift reports”); communication between unit staff and supervisor or manager (select “Between supervisor and staff”); communication among healthcare professionals working within a designated team or service (select “Among interdisciplinary teams”)

With other organizations or outside providers

Ineffective communication with other organizations or outside providers contributed to the event.

INCLUDES: different facility or location within the same healthcare system

Other (please describe) Any other factor related to communication among facility personnel, not included in the list above, which contributed to the event.

INCLUDES: inadequate available information that is not covered by one of the existing factors

Culture Ineffective communication related to cultural differences between facility personnel and the patient or patient’s family contributed to the event.

INCLUDES: failure to recognize cultural prohibitions and preferences

EXCLUDES: language barriers (select “Language”)

Language A component of language that impacted the communication between patients and facility personnel contributed to the event.

INCLUDES: spoken language; American Sign Language (ASL); pronunciation or accent; lack of or inappropriate translation services

Miscommunication Miscommunication between facility personnel and the patient or patient’s family contributed to the event.

INCLUDES: incorrect information regarding condition, medications, etc., provided to or by patient/resident or patient/resident’s family

Patient/resident did not use call light Patient/resident does not use call light to communicate needs with staff.

INCLUDES: any reason a patient/resident does not use a call light (e.g., patient cannot remember to use call light, patient desire for privacy or independence, patient does not want to bother staff)

EXCLUDES: call light not available (select “Device or supply availability”); call light not working (select “Device or supply function”); call light alarms turned off or silenced (select “Device or supply use error”); patient/resident not provided instruction for using call light (select “Miscommunication”)


Factor Definition

Patient/resident unable to communicate

Patient/resident’s inability to communicate contributed to the event.

INCLUDES: patient/resident nonverbal; patient/resident unable to communicate due to condition

EXCLUDES: patient/resident provides incorrect information or does not disclose information to care team (select “Miscommunication”)

Other (please describe) Any other factor related to communication between facility staff or providers and the patient or patient's family not included in the list above, which contributed to the event.


Device, equipment, or supply Factor Definition

Availability The availability, or lack thereof, of a device, equipment, or supply contributed to the event.

INCLUDES: device, equipment or supply not adequately stocked; device, equipment or supply not available when needed; device, equipment or supply not accessible when needed; device, equipment or supply correct size not available; device, equipment or supply available when it should not have been

EXCLUDES: shortages (select “Shortage”)

Design The design of a device, equipment, or supply, regardless of how it functions, contributed to the event.

INCLUDES: device or equipment display or controls not well-designed, difficult to read, or difficult to program; device, equipment or supply awkward to use correctly; device, equipment, or supply did not have built in safety features

EXCLUDES: device, equipment, or supply was not designed for the task for which it was being used (select “Use or selection by a healthcare provider or staff”)

Function (e.g., defective, non-working)

The function of a device, equipment, or supply, regardless of how it is designed, contributed to the event.

INCLUDES: defective or non-working device, equipment, or supply (including defective or dysfunctional alerts); device display or controls not functioning; broken or defective device, equipment, or supply that was awaiting repair contributed to the event

EXCLUDES: device, equipment, or supply that functioned as intended, but whose design contributed to the event (select “Design”)

Maintenance Routine maintenance, or lack thereof, of a device, equipment, or supply contributed to the event.

INCLUDES: device, equipment, or supply did not meet code, specifications, or regulations; inadequate maintenance log; inadequate or delayed maintenance; inadequate cleaning or sterilization

EXCLUDES: broken or defective device, equipment, or supply that was awaiting repair contributed to the event (select “Function”)

Shortage Manufacturer shortage of a device, equipment, or supply contributed to the event.

INCLUDES: device, equipment, or supply not readily available due to a manufacturer shortage; medication supply shortages

EXCLUDES: failure to properly stock supplies (select “Availability”)


Factor Definition

Use or selection by healthcare provider or staff

The incorrect use or inappropriate selection of a device, equipment, or supply by a healthcare provider or staff member contributed to the event.

INCLUDES: provider or staff member did not use the device, equipment, or supply correctly; provider or staff member did not select the correct device, equipment, or supply for the task at hand

EXCLUDES: device, equipment, or supply did not function properly (select “Function”); design of the device, equipment, or supply prohibited the provider or staff from using the device correctly (select “Design”); device, equipment, or supply was used incorrectly by a patient or resident (select “Use by patient/resident””); wrong device, equipment, or supply was selected for use by a patient or resident (select “Use by patient/resident””)

Use by patient/resident The selection of a device, equipment, or supply for use by a patient/resident was incorrect or the patient/resident used the device incorrectly.

INCLUDES: device, equipment, or supply was used incorrectly by a patient/resident; wrong device, equipment, or supply was selected for use by a patient/resident

EXCLUDES: device did not function properly (select “Function”); design of the device prohibited the provider or staff from using the device correctly (select “Design”); provider or staff member did not use the device, equipment, or supply correctly (select “Use or selection by healthcare provider or staff”); provider or staff member did not select the correct device, equipment, or supply for the task at hand (select “Use or selection by healthcare provider or staff”)

Other (please describe) Any other factor related to the device, equipment, or supply, not included in the list above, contributed to the event.

INCLUDES: recalls


Human or environmental Human or environmental factors may be internal to individual staff members (e.g., fatigue, health

issues) or related to the physical environment (e.g., clutter, lighting).

Factor Definition

Alarm fatigue

Desensitization to alarms resulting from alarms sounding in the absence of real healthcare problems, contributed to the event.

INCLUDES: alarm fatigue related to alarms on equipment, computers, barcode devices, telemetry monitors, call lights

EXCLUDES: health information technology (HIT) alerts and notifications such as those in the electronic health record or pharmacy systems (see "HIT" questions on Event Tab)

Clutter

Clutter in the environment contributed to the event.

INCLUDES: unnecessary or unorganized paper, supplies, documents, equipment in work spaces, patient rooms, or hallways

Interruptions or distractions

Interruptions or distractions contributed to the event.

INCLUDES: cell phones, pages, side conversations; interruptions during a procedure or while trying to complete a task

EXCLUDES: alarm fatigue (select “Alarm fatigue”)

Lighting Lighting conditions contributed to the event.

INCLUDES: Poor or inadequate lighting; lighting that creates glare

Noise

Noise in the environment contributed to the event.

INCLUDES: ambient noise levels from construction, equipment, radios, televisions

EXCLUDES: alarm fatigue (select “Alarm fatigue”), side conversations (select “Interruptions or distractions”)

Provider or staff fatigue

Fatigue that influenced concentration, judgment, or focus, of provider or staff involved in the event contributed to the event.

EXCLUDES: patient fatigue (select applicable “Patient” factors); alarm fatigue (select “Alarm fatigue”)

Provider or staff health issues

Health issues that influenced concentration, judgment, or focus of provider or staff involved in the event contributed to the event.

EXCLUDES: patient health issues (select applicable “Patient” factors)

Provider or staff stress

Stress that influenced concentration, judgment, or focus of provider or staff involved in the event which contributed to the event.

EXCLUDES: stress experienced by patients (select applicable “Patient” factors)

Work area design and specifications

Work area design and/or specifications contributed to the event.

INCLUDES: layout of work area; traffic patterns; location of supplies and equipment; size of doors, rooms or hallways; obstructed visibility

EXCLUDES: device or supply design or function (select applicable “Device or supply” factors)

Other (please describe)

Any other factor related to human or environmental factors, not included in the list above, contributed to the event.


Organizational Factor Definition

Adequacy of budget

An inadequate budget contributed to the event.

INCLUDES: unit budget; facility budget

Assignment or work allocation

Conditions related to staff assignment or work allocation contributed to the event.

INCLUDES: delegation of task or care to inadequately prepared staff; inappropriate staff assignment; staff assigned to the wrong unit or patient; temporarily assigned internal facility staff (e.g., relief, float, resource, travelers)

EXCLUDES: lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”); inadequate or disproportionate staffing levels, chronic or acute staffing problems, insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”); frequent changes in facility or unit staff (select “Staffing turnover”)

Culture of safety

The facility’s culture of safety (or lack thereof) contributed to the event.

INCLUDES: lack of acknowledgment of the high-risk nature of an organization's activities; an environment where individuals are unable to report adverse events or near misses without fear of reprimand or punishment; collaboration across ranks is not encouraged to seek solution to patient safety problems; lack of organizational commitment of resources to address safety concerns; behavior or behaviors from providers or staff that undermine a culture of safety, including overt actions such as verbal outbursts and physical threats as well as passive activities such as refusing to perform tasks or uncooperative attitudes (e.g., reluctance or refusal to answer questions, return phone calls or pages, condescending language, impatience with questions or consistently arriving late without regard to team or patient)

Internal reporting

Facility’s internal system for reporting adverse events or unsafe conditions contributed to the event.

INCLUDES: staff were unaware of how to make an internal report, or what should be reported; internal reporting is not consistent

EXCLUDES: facility does not have an internal incident reporting system, or does not analyze internal reports to identify areas of risk (select “Systems to identify risk”)

Job orientation or training

The inadequacy of the facility’s job orientation or training contributed to the event.

INCLUDES: routine job training; in-service education; competency training; job orientation; availability of training programs

EXCLUDES: lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”)

Management or leadership skills

Ineffective or inadequate management or leadership skills contributed to the event.

INCLUDES: inaction around staff accountability; lack of knowledge of staff competencies, follow-through; inadequate skills in motivation, change, supervision


Factor Definition

Staff competencies

Inadequate staff competencies contributed to the event.

INCLUDES: lack of staff understanding, technical skill, clinical knowledge; staff familiar with policy or procedure, but performed procedure incorrectly

EXCLUDES: competency training (select “Job orientation or training”); delegation of task or care to inadequately prepared staff (select “Assignment or work allocation”); inappropriate staff assignment (select “Assignment or work allocation”); staff assigned to the wrong unit or patient (select “Assignment or work allocation”)

Staffing levels

Staffing levels contributed to the event.

INCLUDES: inadequate or disproportionate staffing levels; chronic or acute staffing problems; inadequate or insufficient numbers and/or types of staff for patient care needs

EXCLUDES: inappropriate staff assignment (select “Assignment or work allocation”)

Staffing turnover

Gaining or losing employees contributed to the event

INCLUDES: frequent changes in facility or unit staff

EXCLUDES: one-time change in staff assignment or work allocation (select “Assignment or work allocation”)

Supervision

Ineffective supervision contributed to the event.

INCLUDES: inadequate supervision during learning process; inadequate supervision of social services staff, activities staff, dietary staff, office staff, clinical staff, etc.

EXCLUDES: inadequate staff competencies (select “Staff competencies”); tasks performed by untrained or inadequately trained staff (select “Job orientation or training”)

Systems to identify risk

Inadequate systems to identify risk in the facility contributed to the event.

INCLUDES: facility does not have an internal incident reporting system; internal reports are not analyzed to identify areas of risk; no system in place to identify areas of risk that have not already resulted in an adverse event or harm to a patient

EXCLUDES: staff were unaware of how to make an internal report, or what should be reported (select “Internal reporting”)

Temporary staffing

Conditions related to the use of temporary staff contributed to the event.

INCLUDES: agency or independent staff filling a short-term position or a vacant shift

EXCLUDES: temporarily assigned internal facility staff (e.g., relief, float, resource, travelers); delegation of task or care to inadequately prepared staff; inappropriate staff assignment; staff assigned to the wrong unit or patient (select “Assignment or work allocation”); inadequate staffing levels, chronic or acute staffing problems, inadequate or insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”); staff was not adequately trained or oriented (select “Job orientation or training”); frequent changes in facility or unit staff (select “Staffing turnover”)


Factor Definition


Any other factor related to organizational factors, not included in the list above, which contributed to the event.


Policy or procedure Includes order sets, protocols, checklists, policies, and procedures.

Factor Definition

Clarity of policy or procedure

Lack of clarity of a policy or procedure (either as written or understood) contributed to the event.

INCLUDES: order sets, protocols, checklists

Policy or procedure absent

Absence of a policy or procedure contributed to the event.


EXCLUDES: outdated policy or procedure (select "Other policy or procedure factor")

Provider or staff unfamiliar with policy or procedure

Provider’s or staff member’s lack of familiarity with the policy or procedure contributed to the event.

INCLUDES: order sets, protocols, checklists; incomplete understanding; acting based on an older version of the policy or procedure

EXCLUDES: staff familiar with policy or procedure, but performed procedure incorrectly (select “Organizational staff competencies”)

Policy or procedure too cumbersome

Policy or procedure was not adhered to because it was felt to be too cumbersome, which contributed to the event.


Work-around more efficient

Policy or procedure was not followed because a work-around was felt to be more efficient, which contributed to the event.



Any other factor related to procedures or policies, not included in the list above, which contributed to the event.

INCLUDES: outdated policy or procedure; policy or procedure is inconsistent with guidelines from professional associations; policy or procedure is not standardized across units/departments; policy or procedure is inaccurate; policy or procedure is unrealistic; policy or procedure is poorly presented or formatted

EXCLUDES: policy or procedure not followed/compliant (why the policy or procedure was not followed/compliant is the contributing factor)


Patient management Factor Definition

Accuracy of care plan

The accuracy of the care plan contributed to the event.

INCLUDES: inaccurate or out of date care plans

EXCLUDES: care plan not followed (select “Implementation of care plan”); partial implementation of care plan (select “Implementation of care plan”)

Follow-up care

The follow-up care, or lack thereof, contributed to the event.

INCLUDES: care related to discharge information relayed to other care facility or home; inadequate or inappropriate follow-up care or patient tracking

Implementation of care plan

The implementation of the care plan, or lack thereof, contributed to the event.

INCLUDES: care plan not followed; partial implementation of care plan

EXCLUDES: inaccurate or out of date care plans (select “Accuracy of care plan”)

Initial diagnosis

The initial diagnosis contributed to the event.

INCLUDES: misdiagnosis; incomplete diagnosis; patient self-diagnosis; initially following incorrect diagnostic path, missed diagnosis; diagnoses based on incorrect or inaccurate laboratory values, test results, or missing communication from outside sources

EXCLUDES: Patient self-diagnosis

Patient/resident assessment

The patient/resident assessment contributed to the event.

INCLUDES: inaccurate assessment; incomplete assessment; untimely assessment; omitted assessment

Response to changing condition or delay in care

Provider or staff response to changing condition or a delay in care contributed to the event.

INCLUDES: delays in treatment related to failure to recognize significance of signs and symptoms, lack of test results, or incorrect or missing information


Any other factor related to patient management, not included in the list above, which contributed to the event.

INCLUDES: patient consent process

EXCLUDES: two or more prescriptions filled at the same time (captured in medication event additional questions)


Patient Factor Definition

Behavioral status

The patient’s behavioral status contributed to the event.

INCLUDES: patient responses of inappropriate anger; patient demonstrates lack of engagement in care plan

EXCLUDES: dementia (select “Mental status”); cognitive impairment (select "Mental status")

Family dynamics or relationships

The patient’s family dynamics or relationships contributed to the event.

INCLUDES: family contradicting staff instructions; dysfunctional relationship between patient and patient's family

EXCLUDES: relationships or dynamics between staff and patient's family (select applicable "Communication" factors)

Fragile health status

The patient’s fragile health status (i.e., health status that resulted in the patient’s condition being less stable and more vulnerable to variations in care) contributed to the event.

INCLUDES: immunocompromised patients; frail elderly;

multiple system failure

EXCLUDES: well-controlled multiple diagnoses (list in “Comorbidities”)

Mental status

The patient’s mental status contributed to the event.

INCLUDES: Alzheimer's Disease and other dementias; any other condition impacting a patient's mental status; cognitive impairments impacting patient's understanding of care and treatment requirements

EXCLUDES: behavioral problems (select "Behavioral status")

Physical limitations

The patient’s physical limitations contributed to the event.

INCLUDES: speech; gait disorders; other limitations that impact a patient's abilities

EXCLUDES: sensory impairment (including hearing, vision, smell, feeling, or other impairments) that impact a patient's ability to react to stimuli (select "Sensory impairment")

Sensory impairment (vision, hearing, balance, etc.)

The patient’s sensory impairment contributed to the event.

INCLUDES: Impairments such as hearing, vision, smell, feeling, or other impairments that impact a patient's ability to react to stimuli.

EXCLUDES: Physical limitations (select "Physical limitations"); cognitive impairment (select "Mental status")


Any other factor related to the patient, not included in the list above, which contributed to the event.

INCLUDES:

Resident assumption of risk; resident-to-resident issues

Documents

Data Dictionary - Oregon Patient Safety Commission · The data dictionary provides detailed descriptions of each element in the reporting form. If you have questions or need more