An event which meets one or more criteria, such as the following; (1) a patient is injured, whether or not the hospital may be liable; (2) the admission was the result of an adverse result of outpatient care; (3) the patient was readmitted because of complications or incomplete care in the previous admission; (4) there were deficiencies in documentation, such as in informed consent procedures or in the medical record; (5) unplanned surgery was done; (6) procedures were employed which did not meet the hospital’s criteria for appropriateness; (7) a problem occurred with use of blood or blood components; (8) a nosocomial (hospital-acquired) infection occurred; (9) drug usage was inappropriate; (10) cardiac or respiratory arrest or death occurred; (11) there was an incident (such as a patient fall); (12) abnormal laboratory or x-ray findings were not followed up; (13) the stay was unusually short or long for the condition; (14) there were problems in obtaining Services; or (15) there was patient or family dissatisfaction. These criteria are paraphrased from the Medical Management Analysis (MMA) system for review of care, which depends heavily on screening for and reporting of APOs.