Sample Reportable Events

Transcription

1 Sample Reportable Events This list serves as a guideline of event types typically reported through the ERS (Event Reporting System), online event reporting software. These examples come from hospitals throughout North America. Various Risk Management resources, such as ECRI, ASHRM, N e v e r E v e n t s ( N a t i o n a l Q u a l i t y F o r u m ) and other sources were referenced to compile this document. Generic Occurrence Criteria for All Areas: Missed diagnosis or misdiagnosis Procedure or test done on wrong patient Reactions/complications to a medical test Transfusion related occurrences/complication from transfusion Patient death or serious injury associated with unsafe administration of blood products Hospital incurred trauma, injury or infection Patient or guest suicide or suicide attempt Complications resulting from a diagnostic or operative procedure Adverse drug reaction or medication error Patient exposure to blood borne pathogens, communicable disease or hazardous chemical substances Awareness of staff of an unusually high incidence of infections amongst the same clinician, physician or unit or an unusual increased occurrence of any infectious/ communicable disease Hospital acquired infection that results in death or permanent loss of function Any professional reporting to work who appears impaired Missing or conflicting documentation in patient's medical record Death or permanent loss of function from a hospital acquired injury Clinical equipment or supply malfunction resulting in complication o r potential for complication 1 Think Pink handout revised Example of Events to Report Eva M. Satori

2 Generic Occurrence Criteria for All Areas (continued): Patient or staff death or serious disability associated with electric shock in the course of a patient care process * Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process * Patient death or serious injury associated with the use of restraints or bedrails Complications from invasive, diagnostic, and monitoring procedures Lack of compliance to department policies, protocols, standards Lack of recognition of symptoms leading to change in patient's status Failure to respond to change in patient condition Quality of nursing/provider interventions Adequacy of information provided patient/family regarding condition Charting misadventures such as omission, commission, unprofessional, and inappropriate Issues related to scope of practice for all staff Any stage 3 or 4 or unstageable pressure ulcer (HAPU) acquired after admission/presentation Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider Discharge or release of patient who is unable to make decisions, to other than an authorized person Abduction of a patient of any age Sexual abuse/assault of a patient within or on the grounds Death or significant injury of a patient or staff member resulting from a physical assault (e.g. battery) that occurs on the grounds * Patient death or serious disability, associated with patient elopement (disappearance) Patient suicide, attempted suicide, or self-harm resulting in serious disability Patients leaving against medical advice or eloping Patient/guest injury Patient/guest assault or mishap All falls - patient and guest (reminder: call HURT team & Security) Department Specific Event Reporting Criteria Surgical Services: Unplanned admission related to surgery or complication History and physical not current and/or present in the record Anesthesia failure Morbidity (vascular, neurological, pulmonary, cardiac, drug reactions, infections, etc.) Trauma incurred during and up to 24 hours after surgery Perioperative death, cardiac or respiratory arrest, or heart attack (intraoperative or immediate post-operative death in an ASA Class I patient) 2 Think Pink handout revised Example of Events to Report Eva M. Satori

3 Surgical Services (continued): Patient death or serious disability resulting from an irretrievable loss of an irreplaceable biological specimen Wrong procedure performed Procedure performed on wrong patient, wrong body part Post-operative neurological deficit not present at admission Failure to obtain written consent, improper consent, or incomplete consent Patient injury resulting from chemical, physical, laser, or electric hazard Incorrect needle, sponge, or instrument count Instrument or medical supply breakage or malfunction (retain, tag and sequester item) Foreign object or material found during surgery (except for bullet, other objects related to the surgery); unintended retention of foreign body Adverse reaction to anesthesia (with effects lasting greater than 4 hours post operatively) Intubation or extubation resulting in injury (teeth, skin, membranes) Operative procedure to repair laceration, perforation, tear or puncture subsequent to the performance of an invasive procedure Re-intubation in OR or PACU (ex. Inadequate reversal or over-medicated) Any event resulting in injury to patient Lost specimen Transfusion error Unplanned admission following an ambulatory surgical procedure (except for observation) Patient leaves AMA or elopes without a responsible adult Patient callback reveals any concerns related to the procedure Serious complications Patient discharged with altered state of consciousness, neurological deficit, or unstabl e vital signs with no follow-up plans documented Refusal of treatment Cancellation day of surgery due to equipment failure Diagnostic testing needed for surgery is omitted or not found when ordered Anesthesia Services: Absence of H&P in medical record Complications (spinal headache, nerve injury, eye injury, pulmonary, dental, aspiration, hoarseness, etc.) Patient complains that sedation was not adequate Anesthesia "ends" more than 20 minutes after surgery completed Misadministration/adverse drug reaction Mal-intubation/re-intubation Development of unexpected cardiac arrhythmia during minor procedure Gas line disconnection Equipment and/or medical supply failures Prolonged recovery time Mortality - any death of a patient 3 Think Pink handout revised Example of Events to Report Eva M. Satori

4 Emergency Services: EMTALA Delayed evaluation, procedure and/or treatment Patient elopes after the physician exam Diagnosis variance with diagnostic service interpretation Turn-around time for diagnostic studies is not within acceptable time limits Misadministration and/or adverse drug Mortality after arrival and within 48 hours of admission Omissions and/or commissions in management of patients On-call doctor does not responds in a timely manner or according to bylaws Complications related to treatment Injury while a patient Patient leaves AMA or leaves AMA without a responsible adult or elopes Patient callback reveals any concerns related to the procedure Obstetrics: Any maternal death Fetal mortality in a pregnancy over 20 weeks Hemorrhage requiring transfusion Any Apgar score less than 6 at one minute and/or less than 8 at five minutes 3rd or 4th degree laceration Malposition accidents and/or extractions Anesthesia-related problem Unattended delivery Unplanned return to delivery or surgical unit Newborn injuries NyICU/Pediatrics: Any Apgar score less than 6 at one minute and/or less than 8 at five minutes Newborn injuries Transfer to special care unit after 24 hours of age Readmission to hospital within 72 hours of discharge Battered/sexually abused child Congenital problems Errors in diagnosis and management Social Work: Inappropriate discharge or referral Inadequate discharge planning Inadequate determination of patient needs (such as DME, Oxygen, etc.) Effectiveness of interventions Problems with community transport/ambulance system Patient/family complaint 4 Think Pink handout revised Example of Events to Report Eva M. Satori

5 Pathology & Medical Laboratory Services: Preservation of specimen integrity Complications from lab draw Repeat testing due to errors Labeling error & lost specimen Transfusion error Patent death or serious injury resulting from a failure to follow up or communicate laboratory or pathology results Pharmacy: Event of outdated drugs found on code carts Drug reactions and medication errors Inappropriate response time to STAT orders Patient death or serious injury associated with medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) Behavioral Health: Elopement or AMA Issues related to consent for treatment and right of refusal HIPAA related concerns and privacy issues Reports of abuse by a patient or staff member against another patient or guest * Rehabilitation Program/Services Indicators: Injury acquired during treatment Request for change of therapist Poor or inadequate quality of treatment techniques Availability of services Home Care Services: Admission criteria not followed Transfers to acute care setting Injury in the home with staff present Unplanned transfers to hospital Unscheduled visits due to omission of care Staff expertise is not matched to patient need(s) Unsafe work environment Treatment provided without a doctor's order Procedure incorrectly performed by family member Care provided outside the scope of practice Cardiac arrest Failure to obtain proper consents Injury from malfunctioning equipment Loss or damage to personal properly Unsafe environment for patient 5 Think Pink handout revised Example of Events to Report Eva M. Satori

6 Respiratory Care Services: A change in the patient's clinical condition due to equipment failure Hook-up to wrong medical gas or in which a line designated for 02 or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances Radiology/Nuclear Medicine Services: Repeated imaging studies due to error Misadministration of radionuclide Turn-around time not within acceptable limits Any intraoperative repeat films Any ultra-operative repeat films Patent death or serious injury resulting from a failure to follow up or communicate radiology test results Death or serious injury of a patient or staff associated with introduction of metallic object into the MRI area Dietary: Inadequate or incorrect administration of tube feedings Accuracy of diet orders Wrong diet consumed Patient satisfaction or dissatisfaction Product or device/biomedical: Equipment failure during a patient procedure Known recall of a product, service or equipment Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided. Patient death or serious injury associated with the use or function of a device, in which the device is used for functions other than as intended Patient death or serious injury associated with intravascular air embolism *Note: Employee injuries, exposures and illness are to be reported to Employee Health For additional examples for specific/specialty areas - contact Risk Management x Think Pink handout revised Example of Events to Report Eva M. Satori