The reporting of any death in a healthcare facility is required (not related to NQF), with the exception of a “death due to natural causes” as understood in a general meaning and for which it has been established that the cause of death is not due to any contributing factors by the healthcare facility.

Each medical facility shall provide to the Division, in the form prescribed by the State Board of Health, a summary of the reports submitted by the medical facility regarding sentinel events during the immediately preceding calendar year.

Facilities must report wrong surgical or other invasive procedure performed on a patient, or any surgical procedure performed incorrectly, defined as any surgical or other invasive procedure performed on a patient that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens implants, lesion removal, injection into joints. Excludes emergent situations that occur in the course of surgery or other invasive procedures and/or whose exigency precludes obtaining informed consent..

Facilities must report any incident in which systems designed for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas, or are contaminated by toxic substances. Intended to capture events in which the line is attached to a reservoir distant from the patient care unit or in a tank near the patient such as E-cylinders, anesthesia machines.

Facilities must report artificial insemination with the wrong donor sperm or wrong egg.

Facilities must report surgery or other invasive procedure performed on the wrong patient, defined as any surgery or invasive procedure on a patient that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens implants, lesion removal, injection into joints. Intended to capture surgical procedures (whether or not completed) initiated on one patient intended for a different patient.

Facilities must report patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting. Excludes deaths resulting from self-inflicted injuries that were the reason for admission/presentation to the healthcare facility.

Facilities must report any surgery or other invasive procedure performed on the wrong site, defined as any surgery or other invasive procedure performed on a body part or site that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens implants, lesion removal, injection into joints. Excludes emergent situations that occur in the course of surgery or other invasive procedure and/or whose exigency precludes obtaining informed consent. Intended to capture instances of: surgery or other invasive procedure on the right body part but on the wrong location/site on the body; e.g., left/right (appendages/organs), wrong digit, level (spine), stent placed in wrong iliac artery, steroid injection into wrong knee, biopsy of wrong mole, burr hole on wrong side of skull; delivery of fluoroscopy or radiotherapy to the wrong region of the body; use of incorrectly placed vascular catheters; use of incorrectly placed tubes (for example, feeding tubes placed in the lung or ventilation tubes passed into the esophagus).

Facilities must report sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting. Language and definitions may vary based on state statute; however, the principle and intent remain regardless of language required based on jurisdiction.

Facilities must report patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting. Intended to capture instances where physical restraints are implicated in the death, e.g., lead to strangulation/entrapment, etc.