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