Quality Capture Application

Quick Event Reporting

Airway obstruction

Bradycardia

Case Delay

Difficult Intubation

Equipment/Device Failure or Malfunction

Hemodynamic Instability

Inadequate pain control

Post-Operative Nausea and Vomiting

What Happened?

Select	Category	Description
Select	Category	Description
Acidemia	Blood	The accumulation of excess hydrogen ions or depletion of alkaline reserve (bicarbonate content) in the blood and body tissues resulting in an arterial blood pH < 7.35
Acute Kidney Injury (AKI)	Patient injury	New kidney damage or a sudden decrease in kidney function. Criteria include:<br />1. Increase in serum creatinine (Cr) > 0.3 mg/dl within 48 hours<br />2. Increase in Cr to > 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days<br />
Adverse Drug Reaction	Medication	Any unexpected, unintended, undesired, or excessive response to a drug that requires discontinuing the drug (therapeutic or diagnostic), changing the drug therapy, or modifying the dose (except for minor dosage adjustments). The adverse reaction must be severe enough that it requires prolonged observation or stay in a health care facility, necessitates supportive treatment, negatively affects prognosis, or results in temporary or permanent harm, disability, or death
Airway obstruction	Airway management	An acute respiratory dysfunction that produces reduced airflow into the alveoli and an arterial oxygen saturation less than 90% and that results in bradycardia or other clinical signs of hypoxia; the obstruction can be anatomically localized (e.g., tumor, stricture, foreign body, laryngospasm) or generalized (e.g., bronchospasm, asthma)
Airway Trauma	Airway management	An injury to any of the structures or tissues of the mouth, nasopharynx, oropharynx, or larynx resulting from the use of any airway device such as laryngoscope, oral or nasal airway, endotracheal tube, or stylet
Amniotic Fluid Embolism	Other	An obstetric emergency resulting from amniotic fluid, fetal cells, hair, or other debris that enters the maternal circulation via placental vessels and triggers an immune reaction
Anaphylaxis	Other	A severe, life-threatening allergic response, which is rapid in onset and characterized by a sudden drop in blood pressure and/or respiratory insufficiency
Arrhythmia	Cardiovascular	New onset of an abnormality of the cardiac rhythm; a cardiac rhythm other than normal sinus rhythm
Aspiration	Respiratory	The entry of material (e.g., food, liquid, gastric contents) into the respiratory tract and accompanied by consistent radiologic findings
Awareness	Other	A scenario in which a patient becomes conscious during a procedure performed under general anesthesia and subsequently has recall of these events
Bradycardia	Cardiovascular	Significant slowness of the heart rate that poses a threat to the patient and requires treatment
Burn injury	Patient injury	Unintentional damage to tissue caused by excessive heat; a lesion caused by fire, heat or any other cauterizing agent, including friction, caustic agents, electricity, radiation, or electromagnetic energy
Cannot ventilate	Airway management	Inability to force oxygen into the trachea and alveoli for the purpose of oxygenating the blood in the pulmonary capillaries and removing carbon dioxide
Cardiac arrest	Cardiovascular	The unplanned cessation of the mechanical activity of the heart as confirmed by the absence of signs of effective circulation.Cardiac compression and/or defibrillation may be required for treatment
Case Cancelled After Anesthesia Induction Time	Administration	A scheduled procedure that is not performed on the scheduled procedure day and the decision not to perform the procedure takes place after Anesthesia Induction Time but before Procedure/Surgery Start Time
Case Cancelled Before Anesthesia Induction Time	Administration	A scheduled procedure that is not performed on the scheduled procedure day and the decision not to perform the procedure takes place after Anesthesia Start Time but before Anesthesia Induction Time
Case Cancelled Before Anesthesia Start Time	Administration	A scheduled procedure that is not performed on the scheduled procedure day and the decision not to perform the procedure takes place before Anesthesia Start Time
Case Delay	Administration	The Surgery/Procedure Start Time occurs significantly later than expected in the context of institutional norms
Central Line Placement Injury	Patient injury	A pneumothorax, hemothorax, or thoracic duct, cardiac, or vascular injury that results from an attempted or completed insertion of a central venous catheter
Central Line-Associated Bloodstream Infection (CLABSI)	Infection	A primary bloodstream infection that develops in a patient with a central line in place within the 48-hour period prior to the infection onset.<br /><br />Criteria for diagnosis include any of the following:<br /><br />• Criteria 1: Patient has a recognized pathogen cultured from one or more blood cultures AND organism cultured from blood is NOT related to an infection at another site.<br /><br />• Criteria 2: Patient has at least one of the following signs or symptoms: fever (>38 degrees C), chills or hypotension AND signs and symptoms and positive laboratory results (two or more positive blood cultures drawn on separate occasions) are NOT related to an infection at another site<br /><br />• Criteria 3:Patient < 1 year of age has at least one of the following signs or symptoms: fever (> 38 degrees C core), hypothermia (<36 degrees core), apnea, or bradycardia AND signs and symptoms and positive laboratory results (two or more positive blood cultures drawn on separate occasions) are NOT related to an infection at another site<br />
Cerebrovascular Accident	Neurological-CNS	The sudden death of neurons in a localized area of brain due to inadequate blood flow that produces motor, sensory, or cognitive dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory) that persists for more than 24 hours
Coagulopathy	Blood	The impairment, inability or incapacity of the blood to form clots and is associated with clinical bleeding
Coma	Neurological-CNS	A state of profound unconsciousness, not present prior to the initiation of anesthetic care, in which the individual cannot be awakened, fails to respond normally to external stimuli, and does not initiate voluntary actions. Exclude coma due to prolonged anesthetic effect or hypothermia (temp <34 degrees C)
Corneal Injury	Patient injury	A corneal injury is either a corneal abrasion (a scratch or scrape on the cornea, the clear front window of the eye that transmits and focuses light into the eye) or exposure keratitis (inflammation of the cornea from drying of the corneal tear film)
Death	Other	The irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration, and brain activity; the end of life
Deep Vein Thrombosis	Blood	One or more blood clots (thrombus) within a large vein, usually in the thigh or calf
Delayed Emergence	Neurological-CNS	Failure of the patient to recover consciousness or normal function within 60 minutes after discontinuing the administration of anesthetic drugs used to produce sedation or general anesthesia; this condition often requires the escalation of planned care
Delirium	Neurological-CNS	An altered state of consciousness marked by confusion, disorientation or temporary memory dysfunction, difficulty in sustained attention to stimuli, disordered thinking and perception.There must be evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition or that the condition developed during substance intoxication, or during or shortly after, a withdrawal syndrome
Difficult Intubation	Airway management	Problematic or challenging insertion of an endotracheal tube into the patient's trachea, requiring at least 3 attempts by one or more skilled individuals
Difficult Mask Ventilation	Airway management	The inability of an unassisted trained anesthesia provider to maintain the oxygen saturation as measured by pulse oximetry to > 92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation
Electrolyte Abnormality	Lab abnormalities	A physiologic disorder in which there are fewer or more than normal levels (lower or higher concentration) of serum electrolytes (minerals found in the blood, body fluids, and urine necessary for the body to function properly)
Emergence Delirium	Neurological-CNS	A state of mental confusion, agitation and disinhibition associated with hyperexcitability, crying, restlessness and hallucinations occurring during the emergence from general anesthesia
Equipment/Device Failure or Malfunction	Equipment/Device	The medical device did not provide the expected service or was not functioning as per its specifications
Failed Intubation	Airway management	Inability to insert or pass an endotracheal tube into the trachea
Fall	Patient injury	A sudden, unintentional downward displacement of a (patient's) body to the floor or other object, excluding those resulting from violence or other purposeful act, with or without a resultant injury
Fat Embolism	Blood	Fat tissue passes into the bloodstream and triggers an immune reaction, hemodynamic instability, or organ damage
Hemodynamic Instability	Cardiovascular	An unplanned significant change in global or regional perfusion for more than 30 minutes that may not adequately support normal organ function as indicated by abnormalities in one or more of the following parameters: heart rate, mean arterial blood pressure, or cardiac index that requires treatment with multiple doses or continuous administration of vasoactive agents
High Spinal or Epidural	Procedural	Neuraxial anesthesia in which the level of sensory denervation extends at least to the second thoracic dematome and that produces hypotension, bradycardia, and/or respiratory insufficiency that requires intubation or ventilatory assistance
Hypercapnia	Blood	Abnormally increased arterial carbon dioxide tension greater than 45 mmHg measured in arterial blood at standard temperature
Hyperglycemia	Lab abnormalities	An abnormally high concentration of glucose (greater than 200 mg/dl or 11.1 mmol/l) in the circulating blood
Hypertensive Episode	Blood	An unplanned elevation of the systemic arterial blood pressure to a level likely to induce adverse consequences (arbitrarily defined in adults as a systolic or diastolic blood pressure more than 20% above baseline or a systolic pressure greater than 190 mmHg or diastolic pressure greater than 110 mmHg and lasting for more than 10 minutes)<br /><br />Pediatric HYPERTENSION is determined by the patient’s age and body size.The values for:<br />Full-term newborn systolic pressure is greater than 100 mmHg or diastolic greater than 70 mmHg; <br />Age 1 to 3 yrs, systolic greater than 114 -120 mmHg or diastolic greater than 66-75 mmHg; <br />Age 4 to12 yrs, systolic greater than 122-135 mmHg or diastolic greater than 79-91 mmHg<br />
Hyperthermia	Other	An unplanned, abnormally increased core body temperature (greater than 38.3 degrees Celsius or 100.9 degrees Fahrenheit)
Hypoglycemia	Lab abnormalities	An abnormally low concentration of glucose in the circulating blood;<br />For adults, less than 70 mg/dl;<br />For neonates, less than 45 mg/dl; <br />For children (less than age 12 yr),less than 60 mg/dl<br />
Hypotensive Episode	Blood	An unintentional low systemic arterial blood pressure at a level that may result in inadequate perfusion of critical organs such as the brain, kidney, or heart (arbitrarily defined in adults as a systolic blood pressure less than 20% below the patient's baseline or a systolic blood pressure less than 80 mmHg or a diastolic blood pressure less than 50 mmHg lasting for more than 10 minutes)
Hypoxemia	Blood	A persistent abnormal, low partial pressure of oxygen in the arterial blood (less than 60 mmHg measured at standard temperature or an arterial oxygen saturation of less than 90%)
Inadequate pain control	Pain	Ineffective regulation and/or management of an unpleasant sensation associated with actual or potential tissue damage from an acute or chronic condition and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors
Inadequate Reversal of Neuromuscular Block	Other	Patient weakness, resulting in inadequate ventilation, swallowing, airway maintenance or insufficient strength, after administration of a medication to counter or neutralize the effect of a previously administered neuromuscular blocking agent (a medication that produces paralysis or weakness by preventing the activation of skeletal muscles by the nervous system at the myoneural junction).INADEQUATE REVERSAL OF NEUROMUSCULAR BLOCK may also occur when no reversal agent was administered because the clinician judged that none was necessary after use of a neuromuscular blocking agent
Infection following Epidural or Spinal Anesthesia	Infection	Infectious complications associated with neuraxial anesthesia and analgesia:<br /><br />Superficial soft tissue infection along the course of an epidural/spinal catheter or needle placement track <br />Swelling, local erythema and tenderness in combination with any of the following: (a) Fever (>38.0 degrees C); (b) Drainage; (c) Positive culture from the area; and/or(d) Leukocytosis >12/nl or CRP>20 mg/L<br /><br />Epidural abscess<br />Radiological evidence of a mass in the epidural space consistent with an epidural abscess within 30 days following epidural/spinal needle/catheter placement/catheter removal or attempted epidural/spinal placement in combination with any of the following: (a) Fever (>38.0 degrees C); (b)Drainage; (c) Positive culture from surgical exploration or puncture; (d) Leukocytosis >12/nl or CRP>20 mg/L; (e) Local erythema; (f) Local tenderness; (g) Focal back pain; and/or(h) Neurologic deficit<br /><br />Meningitis associated with central neuraxial block <br />Spinal or epidural block (catheter insertion/removal) in the last 72 hours in combination with: (a) New onset of central neurologic symptoms; (b) Headache; (c) Stiff neck;(d) Fever >38.0 degrees C; (e) Positive CSF culture; and/or (f) Meningitis specific antibiotic therapy started<br /><br />Epidural infection with sepsis <br />Diagnostic criteria of superficial soft tissue infection or epidural abscess or Meningitis in combination with positive blood culture with the same organism isolated from puncture site or abscess or clinical diagnosis of sepsis
Infection following Peripheral Nerve Block	Infection	Peripheral nerve block associated superficial soft tissue infection<br />Swelling, local erythema, and tenderness along the catheter or needle placement track in combination with any of the following: <br />a. Fever (> 38.0 degrees C); <br />b. Drainage; <br />c. Positive culture from the area; <br />d. Leukocytosis >12/nl or CRP>20mg/L<br /><br />Peripheral nerve block associated abscess or deep tissue infection <br />Evidence of an abscess or fluid collection consistent with an infectious process by imaging or surgical exploration within 30 days following peripheral nerve block needle placement/catheter removal or attempted placement, especially if in combination with any of the following: <br />a. Fever (>38.0 degrees C); <br />b. Neurologic deficit; <br />c. Drainage; <br />d. Positive culture from surgical exploration or puncture; <br />e. Leukocytosis >12/nl or CRP>20 mg/L<br /><br />Peripheral nerve block associated infection with sepsis<br />Diagnostic criteria of superficial soft tissue infection or abscess or deep tissue infection in combination with positive blood culture with the same organism isolated from puncture site or abscess or clinical diagnosis of sepsis.
Itching	Pain	An irritating sensation in the skin or mucous membranes that arouses the desire to scratch or rub the affected bodily areas
IV Infiltration	Other	Leakage of exogenously administered intravenous fluid from a catheter into the tissue surrounding the vein thereby preventing fluid or medications from reaching the circulation and producing the intended effect
Kidney Failure	Other	Kidney failure is defined as either: (1) a level of GFR to <15 mL/min/1.73 m2, which is accompanied in most cases by signs and symptoms of uremia, or (2) a need for initiation of kidney replacement therapy (dialysis or transplantation) for treatment for complications of decreased GFR, which would otherwise increase the risk of mortality and morbidity
Local Anesthetic Systemic Toxicity	Other	Major adverse effects observed following injection of a local anesthetic resulting in elevated plasma drug concentration that produces seizures, somnolence, loss of consciousness, respiratory depression/apnea, bradycardia/asystole, or ventricular tachycardia/fibrillation
Malignant Hyperthermia	Other	A potentially fatal, inherited disorder usually associated with the administration of volatile anesthetics and/or succinylcholine.The disorder is due to an acceleration of metabolism in skeletal muscles and may produce muscle rigidity, masseter spasm, tachycardia, elevated core temperature, increased carbon dioxide and acid production, and muscle breakdown resulting in myoglobinuria
Medication Error	Medication	Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use
Multiple Organ Failure	Other	Altered function of one or more organs (vital body system) such that homeostasis cannot be maintained without intervention
Myocardia Ischemia	Cardiovascular	A temporary condition in which there is inadequate circulation of blood and transport of oxygen and glucose via the coronary arteries to the heart muscle but does not result in death of myocardium.It may be diagnosed by clinical symptoms of angina, ECG (ST segment or T wave) changes, new myocardial wall motion abnormality, or small increases in troponin
Myocardial Infarction	Cardiovascular	Blockage of blood flow in a coronary artery causing damage or death of a portion of the heart muscle.Diagnostic criteria: (ONE from below)<br /><br />1. Documented ECG changes indicative of acute MI with one or more of the following<br />a. ST elevation > 1 mm in two or more contiguous leads not resolved within 20 minutes<br />b. New left bundle branch block<br />c. New q-wave in two or more contiguous leads<br /><br />2. New elevation in troponin greater than 3 times the upper level of the reference range in the setting of suspected myocardial infarction. <br /><br />3. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality<br />
OR Fire	Patient injury	Combustion in which fuel or other material is ignited and combined with oxygen, giving off light, heat, and/or flame on or near patients who are under anesthesia care
Perioperative Visual Loss	Neurological-CNS	Total or partial loss of sight in one or both eyes after non-ocular surgery not caused by direct trauma or injury to the eye or the central nervous system
Peripheral Neurologic Deficit after Regional Anesthesia	Neurological-CNS	In a patient that has received regional anesthesia or analgesia, there is impaired sensory and/or motor and/or autonomic function that persists for more than 72 hours after the last injection of local anesthetic or adjuvant drug without other identifiable etiologies
Pneumonia	Respiratory	Inflammation of the lung parenchyma characterized by consolidation of the affected part, the alveolar air spaces being filled with exudate, inflammatory cells, and fibrin produced by infection (bacterial, virus, fungus) or chemical irritation (aspiration)<br /><br />Per the CDC, Pneumonia is defined by:<br /><br />Radiology finding on chest radiograph or CT of new persistent infiltrate, consolidation, or cavitation AND at least one of the following:<br /> • Fever (>38 degree C or > 100.4 degree F)<br /> • Leukopenia (<4,000 WBC/mm3) or Leukocytosis (>12,000 WBC/mm3)<br />• For adults > 70 years old, altered mental status with no other recognized cause<br /><br />AND at least TWO of the following:<br /> • New onset of purulent sputum, or change in character of sputum, or increased respiratory <br /> secretions, or increased suctioning requirements<br /> • New onset or worsening cough, or dyspnea, or tachypnea<br /> • Rales or bronchial breath sounds<br /> • Worsening gas exchange (e.g. O2 desaturations or PaO2/FiO2<240, increased oxygen <br /> requirements, or increased ventilator demand)<br />
Pneumothorax	Respiratory	The unintended presence of air or gas in the pleural cavity, diagnosed by clinical findings or imaging (x-ray, CT, or ultrasound) that results from a regional anesthetic such as supraclavicular brachial plexus block, barotrauma, or instrumentation of the airway
Positioning Injury	Patient injury	Damage or harm to the patient resulting from the placement of his/her body and extremities while under anesthesia
Post-Discharge Nausea and Vomiting	Pain	Nausea (involuntary symptoms resulting from an inclination to vomit, often occurring before vomiting; sickness at the stomach accompanying a loathing for food) and/or vomiting (the ejection of the contents of the stomach through the esophagus and mouth) that occurs after the DISCHARGE FROM PACU/ICU Time
Postdural Puncture Headache	Procedural	The new onset of pain in various parts of the head, not confined to the area of distribution of any nerve, usually occurring within 72 hours of an intended or unintended dural puncture.Signs and symptoms include the headache worsening in the sitting or upright position, usually relieved when the patient is supine, may be accompanied by visual or auditory changes, and may occur more frequently in younger patients when the dura has been punctured.A clinical scenario in which a postdural puncture headache may present may be following placement of an epidural or spinal anesthetic or sometimes following a nerve block in close proximity to the neuraxis (e.g., paravertabral or intescalene block)
Postoperative Cognitive Dysfunction	Other	A loss or decrement from baseline mental function in domains such as learning and memory, judgement, reasoning, verbal abilities, executive functions or perception occurring after anesthesia and surgery
Post-Operative Nausea and Vomiting	Pain	Nausea (involuntary symptoms resulting from an inclination to vomit, often occurring before vomiting; sickness at the stomach accompanying a loathing for food), retching and/or vomiting (the ejection of the contents of the stomach through the esophagus and mouth) occurring between the conclusion of a surgical, diagnostic, or therapeutic procedure for which anesthesia care was provided and the DISCHARGE FROM PACU/ICU Time and requiring the administration of a rescue antiemetic medication for treatment
Prolonged Neuromuscular Block	Other	An unanticipated increased duration of patient weakness after administration of a neuromuscular blocking agent (a medication that produces paralysis or weakness by preventing the activation of skeletal muscles by the nervous system at the myoneural junction)
Pulmonary Edema	Respiratory	Accumulation of extravascular fluid in lung tissues and alveoli diagnosed by chest x-ray, ultrasound, clinical examination, or blood gas analysis
Pulmonary Embolus	Respiratory	A blood clot that travels from or through the heart to the lungs
Respiratory Arrest	Cardiovascular	The unplanned cessastion of spontaneous breating for longer than 60 seconds in adults.For infants, it is cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia
Respiratory Failure	Respiratory	Inadequate pulmonary function , either acute or chronic, that results in hypoxemia or hypercarbia
Seizure	Neurological-CNS	Abnormal electric activity of the neurons in the brain that may have several clinical manifestations such as a sudden, violent involuntary series of contractions of a group of muscles (grand mal seizure); this outcome does not apply to seizures that are medically induced as part of a therapy such as electroconvulsive therapy (ECT)
Sepsis	Infection	Life-threatening organ dysfunction caused by a dysregulated host response to infection
Shivering	Pain	Trembling occurring as a thermoregulatory response to cold or onset of fever
Skin or Mucous Membrane Injury	Patient injury	Damage or harm to any portion of the membranous protective covering of the body
Spinal Cord Injury	Patient injury	Damage to the spinal cord that causes temporary or permanent changes in the patient's motor, sensory, or autonomic function
Spinal Hematoma Following Spinal or Epidural Anesthesia	Patient injury	Symptomatic bleeding within the spinal neuraxis occurring after a completed or attempted epidural or spinal anesthetic.The hematoma may be confirmed by imaging (MRI)
Surgical Site Infection (SSI)	Infection	Superficial Incisional SSI - An infection (defined as the invasion of the body with organisms that have the potential to cause disease) that occurs within 30 days after the principal operative procedure and the infection involves only skin or subcutaneous tissue of the incision and at least one of the following: A. Purulent drainage, with or without laboratory confirmation, from the superficial incision; B. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision; C. Superficial incision is deliberately opened by the surgeon and at least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat<br /><br />Deep Incisional SSI - An infection (defined as the invasion of the body with organisms that have the potential to cause disease) that occurs at the surgical site within 30 days after the principal operative procedure and involves deep soft tissues and at least one of the following: A. Purulent drainage from the deep incision but not from the organ/space component of the surgical site; B. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38⁰ C), localized pain, or tenderness, unless the site is culture-negative; C. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination.<br /><br />Organ/Space SSI - An infection (defined as the invasion of the body with organisms that have the potential to cause disease) that occurs within 30 days after the principal operative procedure and involves any of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during the operation and at least one of the following: A. Purulent drainage from a drain that is placed through a stab wound into the organ/space.; B. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space; C. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination.
Transfusion Reaction	Blood	An immune mediated adverse event consisting of immediate or delayed red blood cell hemolysis, allergic reaction, febrile reaction, or acute lung injury produced by the transfusion of a blood product
Ulcer	Other	A lesion through the skin or nucous membrane resulting from loss of tissue, usually with inflammation
Unanticipated Transfusion	Blood	The unplanned need to administer blood or blood components as demonstrated by absence of a blood sample for type and screen prior to the ANESTHESIA START TIME
Unplanned Conversion to General Anesthesia	Procedural	The need to induce general anesthesia as a result of the failure or inadequacy of the originally initiated anesthetic technique such as regional, neuraxial or local anesthesia.General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.General anesthesia often impairs the patient's cardiovascular function and/or the ability to independently maintain spontaneous ventilation.Under general anesthesia, patient may require assistance in maintaining a patent airway and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug induced depression of neuromuscular function
Unplanned Dural Puncture	Procedural	Unintentionally piercing or perforating the dura mater (the tough, fibrous membrane forming the outer covering of the central nervous system).
Unplanned Endobronchial Intubation	Airway management	Insertion of an endotracheal tube to a depth that permits ventilation of only one lung or a portion of one lung and when the position of the endotracheal tube is not recognized and corrected
Unplanned Esophageal Intubation	Airway management	Unintentionally inserting an endotracheal tube into the esophagus, the anatomic connection between the pharynx and the stomach
Unplanned Hospital Admission	Administration	Transfer of a patient, scheduled for an outpatient procedure, to an in-patient status (patient is assigned a bed in a health care facility to undergo diagnosis and/or receive treatment and care) from an anesthetizing site, PACU, or other clinical location that was not anticipated or arranged at the time that anesthetic care was initiated
Unplanned Hypothermia	Other	An unintended core body temperature lower than 95.9 degrees Fahrenheit (35.5 degrees Celsius) occurring within the 30 minutes immediately before or the 15 minutes immediately after ANESTHESIA END TIME
Unplanned ICU Admission	Administration	Transfer of a patient to an ICU from an anesthetizing site, PACU, or other clinical location that was not anticipated or arranged at the time that anesthetic care was initiated
Unplanned Postoperative Ventilation	Respiratory	The need to provide mechanical pulmonary support that was not anticipated or expected at the time that anesthetic care was initiated
Unplanned Reintubation	Airway management	The need to insert an endotracheal tube resulting from the inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway
Unplanned Reoperation	Administration	The need for or to undertake a surgical procedure that was not planned at the time of the principal operative procedure
Unplanned Tracheal Extubation	Respiratory	Unanticipated or unintentional removal of the endotracheal tube during or after ventilatory support or a surgical procedure
Vascular injury	Patient injury	Damage or harm to an artery or vein resulting from placement of a vascular access device such as an intravenous catheter, central venous catheter, or intra-arterial catheter
Venous Air Embolism	Other	Atmospheric gas, introduced into the vascular system, that travels to an organ such as the heart, brain, lungs, or kidney
Ventilation for more than 24 hours Post Procedure	Respiratory	A patient who has a total of ventilator-assisted respirations greater than 24 hours after the conclusion of a procedure requiring anesthesia care
Wrong Patient	Procedural	Administering anesthesia to or performing a procedure (diagnostic or therapeutic) on a patient for whom it was not intended
Wrong Procedure	Procedural	Performing an incorrect or unintended intervention, treatment, or operation
Wrong Site Regional Anesthesia	Procedural	Injection of a local anesthetic or other medication around a nerve intended to provide analgesia or anesthesia for a surgical, diagnostic, or therapeutic procedure but inadvertently performed on the wrong side, wrong body part, or wrong patient
Wrong Site Surgery	Procedural	An operation on the incorrect or unintended anatomic part, organ, body side, or location or surgery performed on a body part not consistent with the documented informed consent for that patient, excluding emergent situations whose urgency precludes obtaining informed consent from either the patient or an authorized representative

Anesthesia ID

What Happened?