The tool covers CMS' initial list of 10 HACs, including foreign objects retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, manifestations of poor glycemic control, catheter-associated urinary tract infect ion (UTI), vascular catheter associated infection, surgical site infection and deep vein thrombosis (DVT)/pulmonary embolism (PE).

Never event" is an expression in healthcare that refers to events that are never supposed to happen in a hospital -- preventable problems like falls, air embolisms, bedsores, or infections that occur after a patient's admission to the hospital.

There were 12 patients who were seriously injured from a fall, four surgeries in which doctors left a foreign object inside a patient, three medication errors, two suicide attempts, two pressure ulcers (bedsores), one air embolism (gas in the bloodstream), and one burn.