Table 3. Frequency of Events Grouped by Type of Event.
| Event | Overall (n = 379) | Preventable/Ameliorable (n = 267) |
|---|---|---|
| Health care–acquired infections, frequency (%) | 108 (28.5) | 49 (18.4) |
| Catheter-associated urinary tract infection | 22 | 5 |
| Respiratory infection | 45 | 13 |
| Clostridium difficile infection | 14 | 3 |
| Surgical/procedural site infection | 8 | 7 |
| Blood stream infection/sepsis | 5 | 3 |
| Other | 14 | 11 |
| Event related to resident care, frequency (%) | 197 (52.0) | 173 (64.8) |
| Fall with injury | 38 | 34 |
| Skin tear, abrasion, or breakdown | 40 | 37 |
| Pressure ulcer | 56 | 53 |
| Cardiogenic volume overload | 8 | 3 |
| Respiratory distress/failure | 7 | 4 |
| Dehydration/AKI | 5 | 4 |
| Confusion/delirium | 8 | 7 |
| Delay in diagnosis or treatment | 8 | 8 |
| Other (eg, bruise, bowel obstruction, UTI, VTE, incontinence, resident self-harm) | 27 | 23 |
| Event related to medication, frequency (%)a | 64 (16.9) | 39 (14.6) |
| Allergic reaction | 7 | 1 |
| Delirium or other change in mental status | 8 | 7 |
| Gastrointestinal | 10 | 7 |
| Hemorrhagic | 8 | 2 |
| Infection | 10 | 2 |
| Other (eg, AKI, hematologic, hypoglycemic events, hypotension) | 29 | 22 |
| Event related to procedures, frequency (%) | 10 (2.6) | 6 (2.2) |
Abbreviations: AKI, acute kidney injury; UTI, urinary tract infection; VTE, venous thromboembolism.
a
Physician reviewers may have assigned more than 1 type of event related to medication; therefore, the categories were not mutually exclusive.