Facilities must report abduction of a patient/resident of any age, including removal of a patient/resident, who does not have decision-making capacity, without specific notification and approval by staff even when the person is otherwise authorized to be away from the setting.
Facilities must report patient death or serious injury associated with intravascular air embolism that occurs while begin cared for in a healthcare setting, excluding those associated with neurosurgical procedures known to present a high risk of intravascular air embolism. Intended to capture high-risk procedures, other than neurosurgical procedures, that include, but are not limited to, […]
Facilities must report artificial insemination with the wrong donor sperm or wrong egg.
Facilities must report patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting, including operating room flash fires (second-degree), hot water, sunburn in the patient with decreased ability to sense pain, and smoking in the patient care environment.
Facility must report patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting, including contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product. Intended to capture contaminations that can be seen with the naked eye or with use of detection […]
Facilities must report patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended, whether or not the use is intended or described by the device manufacturer's literature. Includes, but is not limited to, catheters, drains, and […]
Facilities must report discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person. Release to “other than an authorized person” includes removing the patient/resident without specific notification and approval by staff, even when the person is otherwise authorized. Examples of individuals who do not have […]
Facilities must report patient or staff death or serious injury associated with an electric shock in the course of a patient care process in the healthcare setting, excluding events involving patients during planned treatments such as electric countershock/elective cardioversion. Intended to capture patient death or injury associated with unintended electric shock during the course of […]
Facilities must report patient death or serious injury associated with patient elopement (disappearance), excluding events involving competent adults with decision-making capacity who leave AMA or voluntarily leave without being seen. The term “elopement” and “competent” adult should be interpreted in accordance with prevailing legal standards in applicable jurisdictions. Of note, an assessment that identifies patients […]
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 […]
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 […]
Facilities must report any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider, including those without licensure to provide the care given, and those with licensure who represent themselves and act beyond the scope of their licensure.
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 […]
Facilities must report death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area, including retained foreign objects, external projectiles, and pacemakers.
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 […]
Facilities must report maternal death or serious injury associated with labor or delivery in a pregnancy while being cared for in a healthcare setting. Includes events that occur within 42 days post-delivery. Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.
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 […]
Facilities must report death or serious injury of neonate associated with labor or delivery in a pregnancy. Includes, for the office-based surgery, birthing center or “home” setting, unplanned admission to an inpatient setting within 24 hours of delivery. Unplanned admission to other than the birth setting should be verified with the identified birth setting.
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.
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 death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs 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 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 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.
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 […]
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 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 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. […]
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 […]
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.
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 […]
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, […]
