Prevention of Adverse Events

Prevention of Adverse Events

Adverse events many times result in hospitalization and drive up the cost of care, impact quality of care, lower quality measure performance and potentially lead to a cascade of events for residents.

Adverse Events Defined

Adverse events are defined by the Office of the Inspector General as harm to a patient or resident as the result of medical care, including the failure to provide needed care.

Adverse Event Categories

  • Medication Events
    • Change in mental status or delirium secondary to medication
    • Excessive bleeding due to anticoagulation medication
    • Falls or other trauma with injury secondary to effects of medication
  • Resident Care Events
    • Fall or other trauma with injury related to resident care
    • Acute kidney injury secondary to fluid maintenance
    • Exacerbations of preexisting conditions resulting from omissions of care
  • Infection Events
    • Aspiration pneumonia and other respiratory infections
    • Catheter Acquired Urinary Tract Infection (CAUTI)

Common Causes of Adverse Events

  • Communication breakdown
  • Misinterpretation of doctor’s orders
  • Equipment failures
  • Mistaken Diagnoses
  • Misuse or overuse of lab tests and other services
  • Falls
  • Medications—wrong meds, misuse or overuse
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