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– ALL USA ADVERSE EVENTS DEFINITIONS –

Definitions are available from JCAHO, NQF, and 30 States' statutes, administrative rules,
and/or guidelines, providing over 650 definitions arranged in 90+ categories. Definitions from programs
reporting outcomes and physicians are also included where there is cross-over with adverse event reporting.

States with Adverse Event Definitions

Please select one of the categories:

 

Definitions for 'Adverse Event'
among US Adverse Event reporting programs

IDENTIFYING INFORMATION
TEXT OF DEFINITIONS
Version 1:  Serious Reportable Event
1.
The NQF provides a list of 27 serious reportable events that should never occur. As such, they are intended to reflect preventable events that are mostly medical errors
Version 2:  Sentinel Event
2.
Adapted from JCAHO Sentinel Event Definition: A Sentinel Event is an event that resulted in an unanticipated death or serious physical or psychological injury. Serious injury specifically includes loss of limb or function.
3.
A "sentinel event" is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Such events are called "sentinel" because they signal the need for immediate investigation and response.
Version 3:  Sentinel Event - including nosocomial infections
4.
"Sentinel event" means an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof, including, without limitation, any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The term includes loss of limb or function. Nevada failed to specify sentinel events in the final approved rule NAC 439.900 - 439.920. [.doc File]. However, in October 2005, Nevada provided a list of events in its Sentinel Event Report Guide [.doc File].
Version 4:  Reviewable Sentinel Event
5.
A subset of specific sentinel events that is subject to review by the Joint Commission. Fifteen described occurrences are enumerated in at least two separate areas on the JCAHO website.
Version 5:  Unusual Occurrence
6.
"Unusual Occurrences": Any occurrence such as epidemic outbreak, poisoning, fire, major accident, disaster, other catastrophe or unusual occurrence which threatens the welfare, safety or health of patients, personnel or visitors shall be reported as soon as reasonably practical, either by telephone or by telegraph, to the local health officer and to the Department.
Version 6:  Occurrence
7.
Colorado defines ‘occurrences’ by stipulating 14 events that "Each health care facility licensed pursuant to section 25-3-101 or certified pursuant to section 25-1.5-103 (1) (a) (II) shall report to the department . ." These 14 events are listed in §25-1-124(2) C.R.S.
Version 7:  Adverse Event
8.
"Adverse Event," according to CT statute, is any of the 27 events on the National Quality Forum's List of Serious Reportable Events or the 6 events on a Connecticut-specific list compiled by the Commissioner of Public Health and adopted as regulations. Connecticut lists 33 adverse events.
Version 8:  Adverse Event
9.
"Serious Adverse Event," is not separately defined in Indiana regulations except as a list of 27 adverse events for hospitals and 22 adverse events for ambulatory surgical centers
Version 9:  Adverse Incident
10.
an event over which healthcare personnel could exercise control and
  • (a) Is associated in whole or in part with medical intervention as described in subsection (17) below rather than the condition for which such intervention occurred, and
  • (b) Is not consistent with or expected to be a consequence of such medical intervention, or
  • (c) Occurs as a result of medical intervention to which the patient has not given his informed consent, or
  • (d) Occurs as the result of any other action or lack thereof on the part of the facility or personnel of the facility, or
  • . . specific events enumerated . . .
Version 10:  Adverse Health Care Event
11.
"Adverse health care event" means any event described in subsections (b) through (g) of 410 ILCS 522/10-15.
Version 11:  Serious Injury
12.
"e;Serious injury" means injury that is life threatening, results in death, or requires a patient to undergo significant additional diagnostic or treatment measures
Version 12:  Major Incident
13.
Each facility must report "major incidents," which are defined within the Board of Registration in Medicine (BMR) Patient Care Assessment regulations. The 5 specified types of "major incidents" are available in 243 CMR §3.08(2).
Version 13:  Adverse Event
14.
"Adverse event" means an unexpected occurrence related to an individual's medical treatment and not related to the natural course of the patient's illness or underlying disease condition.
15.
A major permanent loss of function that is not present when the patient is admitted to the health care facility . . . that is determined to be unrelated to the natural course of the patient's illness or underlying condition or proper treatment of that illness or underlying condition
Version 14:  Level 1 Adverse Event
16.
"Level 1 adverse event" means an adverse event that results in death or serious disability. Per COMAR 10.07.06.04, hospitals must establish a hospital-specific well-defined list of "Level 1" events for reporting.
Version 15:  Level 2 Adverse Event
17.
"Level 2 adverse event" means an adverse event that requires a medical intervention to prevent death or serious disability. Per COMAR 10.07.06.04, hospitals must establish a hospital-specific well-defined list of "Level 2" events for reporting.
Version 16:  Level 3 Adverse Event
18.
"Level 3 adverse event" means an adverse event that does not result in death or serious disability and does not require any medical intervention to prevent death or serious disability. Per COMAR 10.07.06.04, hospitals must establish a hospital-specific well-defined list of "Level 3" events for reporting.
Version 17:  Near Miss
19.
"Near-miss" means a situation that could have resulted in an adverse event but did not, either by chance or through timely intervention
Version 18:  Sentinel Event
20.
Maine adopted the subset of specific sentinel events that is subject to review by the Joint Commission. These 10 occurrences specified in the 2003 statute are not the same as those enumerated on the JCAHO website since JCAHO has added events to this list since the Maine law was passed. The Maine "Sentinel Event" list is provided in 22 MRSA §8752.4A
Version 19:  Serious Disability
21.
"Serious disability" means (1) a physical or mental impairment that substantially limits one or more of the major life activities of an individual or a loss of bodily function, if the impairment or loss lasts more than seven days or is still present at the time of discharge from an inpatient health care facility, or (2) loss of a body part.
Version 20:  Serious Preventable Adverse Event
22.
"Serious preventable adverse event" means an adverse event that is a preventable event and results in death or loss of a body part, or disability or loss of bodily function lasting more than seven days or still present at the time of discharge from a health care facility.
Version 21:  Attempted Occurrences (for criminal events and suicides only)
23.
Special Note: If the unexpected occurrence meets the sentinel event criteria, was one of the following, and occurred on the facility’s premise, then it must be reported: Abduction, Assault, Homicide, Rape and Suicide. All of these include attempted occurrences, as they would minimally cause a risk of harm. If the occurrence was an attempt only, please indicate “Attempted” on the report form, next to the event type.
Version 22:  Incident
24.
Incidents” include patients' deaths or impairments of bodily functions in circumstances other than those related to the natural course of illness, disease or proper treatment in accordance with generally accepted medical standards.
Version 23:  Serious Adverse Event
25.
"Serious adverse event" means an objective and definable negative consequence of patient care, or the risk thereof, that is unanticipated, usually preventable and results in, or presents a significant risk of, patient death or serious physical injury.
Version 24:  Serious Event
26.
"Serious Event:" An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident ...[which is a ‘near-miss’ event]..
Version 25:  Unusual Event
27.
Unusual event” is an unexpected occurrence or accident resulting in death or life-threatening or serious injury to a patient that is not related to a natural course of the patient's illness or underlying condition. An unusual event also includes an incident resulting in the abuse of a patient.
Version 26:  Patient Safety Sentinel Event
28.
Utah defines its "Patient Safety Sentinel Event" by pointing to a list of events in section 3 of the administrative rule, UAC R380-200-2.
Version 27:  Reportable event
29.
The definitions of reportable ‘events’ are stipulated by administrative rules of the Department of Health in WAC 246.320.145(10). The list of 8 items comprises 12 discrete reportable events.
Version 28:  Safety Event
30.
""Safety Events" means an "unexpected occurrence involving death or serious physical or psychological injury or the risk thereof" including: ( i ) Surgical events, (ii) Product or device events, (iii) Patient protection events, (iv) Care management events, (v) Environmental events and (vi) Criminal events. These 6 categories reflect the 27 events patterned after the NQF template.
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