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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 - hospital for treatment • Aspiration pneumonitis/pneumonia with inadequate preventive care • Cascade with opioids … pain and anti-anxiety medication (opioid and benzodiazepine [diazepam]) • Mental status changes due to opioid … analgesics (intravenous hydromorphone) • Somnolence due to anti-anxiety medications (lorazepam and clonazepam … frequent falls resulting in back pain • Cascade with oversedation and hypotension while on multiple opioids … alprazolam) medication • Somnolence while on anti-anxiety medication (alprazolam) • Somnolence while on opioids

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 - Medication Medication-induced delirium or other change in mental status • Significant confusion due to opioids