Serious errors that should be reported
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The National Quality Forum in Washington, DC, recently finalized a list of critical medical errors or "serious reportable adverse events." For more information and the complete list, go to the group’s web site at www.qualityforum.org/. Key adverse events are summarized below:
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.
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.
Wrong surgical procedure performed on a patient. 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.
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.
Intraoperative or immediately postoperative death in an ASA Class 1 patient. Includes all ASA Class 1 patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out. Immediately postoperative means within 24 hours after induction of anesthesia (if surgery not completed), surgery, or other invasive procedure was completed.
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.
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 not limited to, catheters, drains, other specialized tubes, infusion pumps, and ventilators.
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.
Patient death or serious disability associated with patient elopement (disappearance) for more than four hours. Excludes events involving competent adults.
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.
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.
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.
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. Hyperbilirubinemia is defined as bilirubin levels > 30 mg/dl.
Stage 3 or Stage 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.
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.
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