Facilities must report artificial insemination with the wrong donor sperm or wrong egg.
Facilities must report any stage 3, stage 4 and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting, excluding progression from stage 2 to stage 3 if stage 2 was recognized upon admission, and excludes pressure ulcers that develop in areas where deep tissue injury is documented as present on admission/presentation.
Facilities must report patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration). Excludes reasonable differences in clinical judgment on drug selection and dose. Includes, but is not limited to, death or serious injury associated with: a) over- or under-dosing; b) administration of a medication to which a patient has a known allergy or serious contraindication, c) drug-drug interactions for which there is known potential for death or serious injury, and d) improper use of single-dose/single-use and multi-dose medication vials and containers leading to death or serious injury as a result of dose adjustment problems.
Facilities must report patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen, including events where specimens are misidentified, where another procedure cannot be done to produce a specimen, and including progression of an undiagnosed disease or threat of disease that changes the patient's risk status for life, requiring monitoring not needed before the event.
Facilities must report patient death or serious injury associated with a fall while being cared for in a healthcare setting. Includes but is not limited to fractures, head injuries, and intracranial hemorrhage. Of note, an assessment that identifies patients at “risk” of fall, findings of risk accompanied by organizationally defined measures to be taken when risk is identified could be useful in both prevention and event analysis.
Facilities must report patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results. Includes events where failure to report increased neonatal bilirubin levels result in kernicterus. Examples of serious injury are a new diagnosis, or an advancing stage of an existing diagnosis (e.g., cancer). Failure to follow up or communicate can be limited to healthcare staff or can involve communication to the patient.
Facilities must report patient death or serious injury associated with unsafe administration of blood products, including hemolytic reactions and administering blood or blood products a) to the wrong patient, b) that are the wrong type, or c) that have been improperly stored or handled.