Appendix:
Trigger list (Italian Version) Setting Trigger
CARES AND MEDICATION
C1-Transfusion or use of blood products C2-Code/arrest/rapid response team C3-Acute dialysis
C4-Positive blood culture
C5-X-Ray or Doppler studies for emboli or DVT C6-Decrease of greater than 25% in Hb or Ht C7-Patient fall
C8-Pressure ulcers
C9-Readmission within 30 days C10-Restraint use
C11-Healthcare associated infection C12-Hospital stroke
C13-Transfer to higher level of care C14-Any procedure complication C15-Other
MEDICATION CARE M1-Clostridium Difficile positive stool M2-PTT>3,1 –ratio
M3-INR>6 and
M4-Glucose < 50 Mg/Dl
M5-Rising bun or serum creatinine greater than 2 times baseline M6-Vitamin K administration
M7-Anti-allergic drugs use (e.g. AliserinR or AllerganR) M8-Anexate (Flumazenil) use
M9-Naloxone use
M10-Antiemetic use (e.g. administered as needed) M11-Over-sedation/Hypotension
M12-Abrupt medication stop
M13-Other (include eventual Adverse Drug Reaction)
SURGICAL CARE
S1-Return to surgery S2-Change in procedure
S3-Admission to intensive care post
S4-Intubation/reintubation/Bi-Pap in post-anesthesia care unit (PAUC) S5-X Ray intra-op or in PAUC
S6-Intra-op or post-op death
S7-Mechanical ventilation greater than 24 hours post-op S8 Intra-op epinephrine, norepinephrine, naloxone, AnexateR S9-Post-op troponin level greater than 1,5 ng/ml
S10-Injury, repair, or removal of organ S11-Any operative complication
ICU
I1-Pneumonia onset
I2-Readmission to Intensive Care I3-In-unit Procedure
I4-Intubation/Reintubation
PERINATAL CARE
P1- LentogestR use
P2-3rd or 4th degree laceration P3-Platelet counts less than 50.000
P4-Estimated blood loss > 500 Ml (vaginal) OR>1000 ML P5-Specialty consult
P6-Oxytocin agents P7-Instrumented delivery P8-General anesthesia
ER E1-Readmission to ED within 48 hours E2-Time in greater than 6 hours ICU: Intensive Care Unit; ER: Emergency Room
AEs categories (N, % ) per semesters
Semester
AEs related to
surgical procedures HAIs Pressure ulcers
Medication AEs
Medical procedure related AEs
Falls Others
TOT
N % N % N % N % N % N % N %
I. mar 09 - ago 09 13 39,4 11 33,3 1 3,0 6 18,2 1 3,0 1 3,0 33
II. set 09 - feb 10 13 32,5 11 27,5 6 15,0 4 10,0 2 5,0 3 7,5 1 2,5 40
III. mar 10 - ago 10 14 48,3 9 31,0 2 6,9 1 3,4 2 6,9 1 3,4 0,0 29
IV. set 10 - feb 11 4 12,9 5 16,1 11 35,5 5 16,1 1 3,2 4 12,9 1 3,2 31
V. mar 11 - ago 11 10 35,7 10 35,7 1 3,6 2 7,1 0,0 1 3,6 4 14,3 28
VI. set 11 - feb 12 17 51,5 7 21,2 4 12,1 2 6,1 1 3,0 0,0 2 6,1 33
VII. mar 12 - ago 12 12 40,0 8 26,7 4 13,3 5 16,7 0,0 1 3,3 0,0 30
VIII. set 12 - feb 13 11 37,9 6 20,7 2 6,9 4 13,8 6 20,7 0,0 0,0 29
XI. mar 13 - ago 13 16 43,2 11 29,7 4 10,8 2 5,4 0,0 2 5,4 2 5,4 37
X. set 13 - feb 14 13 39,4 9 27,3 3 9,1 3 9,1 5 15,2 0,0 0,0 33
XI. mar 14 - ago 14 16 37,2 11 25,6 6 14,0 7 16,3 2 4,7 1 2,3 0,0 43
Tot 139 38,0 98 26,8 44 12,0 41 11,2 20 5,5 14 3,8 10 2,7 366
