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1. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
   January 01, 2019 - Severe hypoglycemia with hypothermia and confusion (blood glucose of 39) Delirium and other changes in mental … resulting in a subdural hematoma, requiring acute-care hospital care, and ultimately death • Altered mental … leading to renal failure and ultimately death (patient family refused dialysis) Delirium and other mental … lorazepam]) • Delirium while on pain and anti-anxiety medication (opioid and benzodiazepine [diazepam]) • Mental … infection-related temporary harm events • Cascade with sepsis leading to acute kidney injury leading to mental

2. Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
   July 01, 2016 - Likely Preventable, by Clinical Category Adverse Events Related to Medication Delirium or change in mental … hospital Temporary Harm Events Related to Medication Medication-induced delirium or other change in mental

3. Patient Safety Organizations: A Compliance Self-Assessment Guide (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/saguide.pdf
   September 01, 2009 - including demographic data, that relates to the individual’s past, present, or future physical or mental