Harbor:Adverse event mandatory reporting

Overview

There are events which we must report to the state in a timely fashion or face being penalized by State Licensing. Below are some general guidelines for what to report. Please make sure that the ED attending is aware of these events and documents their involvement in the record (HUMC Policy 612B).

Event Types

Events must be reported within 4 hours to both of the following:

  1. Immediate supervisor
  2. SI (Safety Intelligence System entry)
  3. Risk Management x2168

Events to be Reported

  1. Procedure performed on a wrong body part, patient, or the wrong procedure all together.
  2. Death or disability from any medication error, blood product incompatibility, hypoglycemia, intravascular air embolus, falls, or burns that occur while in the ED
  3. Patient death or serious disability through any actions or errors which are not an expected part of the patients medical condition or treatment, including elopement of an incompetent individual or minor, abduction, or assault (physical or sexual).
  4. Retention of a foreign object (e.g. central line guidewire)
  5. Patient suicide or serious injury from suicide attempt while in the ED
  6. Visitor or staff death or severe disability while on hospital grounds for any reason.
  7. An infant discharged to the wrong person.
  8. A maternal death or serious disability within 42 days post delivery
  9. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

(Ref: Reporting Form – Adverse Events -Julie Rees)

(Hospital policies 612A, 612B 5/14, CMO 7/2017)


See Also

References

Authors:

Ross Donaldson