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National
Quality Forum's Serious Reportable Events (Kaiser
& Steegan, 2002)
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Event
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Additional
specifications
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| 1. Surgical events
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| A. Surgery performed on the wrong body part |
Defined as any surgery performed on a body part that
is not consistent with the documented informed consent
for that patient.
Excludes emergent situations that occur in the course
of surgery and/or whose exigency precludes obtaining
informed consent.
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Defined as any surgery performed on a body part that
is not consistent with the documented informed consent
for that patient.
Excludes emergent situations that occur in the course
of surgery and/or whose exigency precludes obtaining
informed consent.
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| B. Surgery performed on the wrong patient |
Defined as any surgery on a patient that is not consistent
with the documented informed consent for that patient.
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| C. Wrong surgical procedure performed on a patient
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Defined as any procedure performed on a patient that
is not consistent with the documented informed consent
for that patient.
Excludes emergent situations that occur in the course
of surgery and/or whose exigency precludes obtaining
informed consent. Surgery includes endoscopies and other
invasive procedures.
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| D. Retention of a foreign object in a patient after
surgery or other procedure |
Excludes objects intentionally implanted as part of
a planned intervention and objects present prior to surgery
that were intentionally retained. |
| E. Intraoperative or immediately post-operative death
in an ASA Class I patient |
Includes 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 induction of
anesthesia (if surgery not completed), surgery, or other
invasive procedure was completed. |
| 2. Product or device
events |
| A. Patient death or serious disability associated
with the use of contaminated drugs, devices, or biologics
provided by the health care facility |
Includes generally detectable contaminants in drugs,
devices, or biologics regardless of the source of contamination
and/or product. |
| B. Patient death or serious disability associated
with the use or function of a device in patient care,
in which the device is used for functions other than as
intended |
Includes, but is not limited to, catheters, drains and
other specialized tubes, infusion pumps, and ventilators. |
| C. Patient death or serious disability associated
with intravascular air embolism that occurs while being
cared for in a health care facility |
Excludes deaths associated with neurosurgical procedures
known to be a high risk of intravascular air embolism. |
| 3. Patient protection
events |
| A. Infant discharged to the wrong person |
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| B. Patient death or serious disability associated
with patient elopement (disappearance) for more than four
hours |
Excludes events involving competent adults. |
| C. Patient suicide, or attempted suicide resulting
in serious disability, while being cared for in a health
care facility |
Defined as events that result from patient actions after
admission to a health care facility. Excludes deaths resulting
from self-inflicted injuries that were the reason for
admission to the health care facility. |
| 4. Care management
events |
| A. Patient death or serious disability 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. |
| B. Patient death or serious disability associated
with a hemolytic reaction due to the administration of
ABO-incompatible blood or blood products |
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| C. Maternal death or serious disability associated
with labor or delivery in a low-risk pregnancy while being
cared for in a health care facility |
Includes events that occur within 42 days post-delivery.
Excludes deaths from pulmonary or amniotic fluid embolism,
acute fatty liver of pregnancy or cardiomyopathy.
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| D. Patient death or serious disability associated
with hypoglycemia, the onset of which occurs while the
patient is being cared for in a health care facility |
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| E. Death or serious disability (kernicterus) associated
with failure to identify and treat hyperbilirubinimia
in neonates |
Hyperbilirubinimia is defined as bilirubin levels >30
mg/dl.
Neonates refers to the first 28 days of life.
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| F. Stage 3 or 4 pressure ulcers acquired after admission
to a health care facility |
Excludes progression from Stage 2 to Stage 3 if Stage
2 was recognized upon admission. |
| G. Patient death or serious disability due to spinal
manipulative therapy |
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| 5.
Environmental events |
| A. Patient death or serious disability associated
with an electric shock while being cared for in a health
care facility . |
Excludes events involving planned treatments such as
electric countershock |
| B. Any incident in which a line designated for oxygen
or other gas to be delivered to a patient contains the
wrong gas or is contaminated by toxic substances |
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| C. Patient death or serious disability associated
with a burn incurred from any source while being cared
for in a health care facility |
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| D. Patient death associated with a fall while being
cared for in a health care facility |
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| E. Patient death or serious disability associated
with the use of restraints or bedrails while being cared
for in a health care facility |
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| 6. Criminal events |
| A. Any instance of care ordered by or provided by
someone impersonating a physician, nurse, pharmacist,
or other licensed health care provider |
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| B. Abduction of a patient of any age |
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| C. Sexual assault on a patient within or on the grounds
of the health care facility |
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| D. Death or significant injury of a patient or staff
member resulting from a physical assault (i.e., battery)
that occurs within or on the grounds of the health care
facility |
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