Log InRegister

Reporting And Data

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 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 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 unintended retention of foreign object in a patient after surgery or other invasive procedure. Includes medical or surgical items intentionally placed by provider(s) that are unintentionally left in place. Excludes a) objects present prior to surgery or other invasive procedure that are intentionally left in place; b) objects intentionally implanted as part of a planned intervention; and c) objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the risk of retention (such as microneedles, broken screws). Intended to capture occurrences of unintended retention of objects at any point after the surgery/procedure ends regardless of setting (post anesthesia recovery unit, surgical suite, emergency department, patient bedside) and regardless of whether the object is to be removed after discovery; unintentionally retained objects (including such things as wound packing material, sponges, catheter tips, trocars, guide wires) in all applicable settings.

Facilities must report intraoperative or immediately postoperative death in an ASA Class I patient, including all ASA Class I patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out. Immediately post-operative means within 24 hours after surgery or other invasive procedure was completed or after administration of anesthesia (if surgery/procedure not completed). ASA Class I patient death associated with the administration of anesthesia whether or not the planned surgical procedure was carried out.

DISCLAIMER
Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.