Serious Reportable Events
Surgical Events
- Surgery performed on the wrong body part.
- Surgery performed on the wrong patient.
- Wrong surgical procedure performed on a patient.
- Retention of a foreign object in a patient after surgery or other procedure.
- Intraoperative or immediately postoperative death in an ASA Class I patient.
Product or Device Events
- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility.
- Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended.
- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.
Patient Protection Events
- Infant discharged to the wrong person.
- Patient death or serious disability associated with patient elopement (disappearance) for more than four hours.
- Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a health care facility.
Care Management Events
- 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).
- Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products.
- Maternal death or serious disability associated with labor or delivery in low-risk pregnancy while being cared for in a health care facility.
- 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.
- Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.
- Stage 3 or 4 pressure ulcers acquired after admission to a health care facility.
- Patient death or serious disability due to spinal manipulative therapy.
Environmental Events
- Patient death or serious disability associated with an electric shock while being cared for in a health care facility.
- 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.
- Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.
- Patient death associated with a fall while being cared for in a health care facility.
- Patient death associated with the use of restraints or bedrails while being cared for in a health care facility.
Criminal Events
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
- Abduction of a patient of any age.
- Sexual assault on a patient within or on the grounds of a health care facility.
- 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 a health care facility.
Source: The National Quality Forum, Washington, DC.
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