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– NATIONAL QUALITY FORUM POLICY –

National Quality Forum (NQF)
27 Serious Reportable Events in Health Care [PDF]

Event Type Description of Event
Surgical
Events
1. Wrong Body Part
Surgery performed on the wrong body part
2. Wrong Patient
Surgery performed on the wrong patient
3. Wrong Procedure
Wrong surgical procedure performed
4. Retained Foreign Body
Retention of foreign object in a patient after surgery or another procedure
5. Death of normal, healthy patient
Death of patient with an ASA class I risk during or immediately after surgery (ASA = American Society of Anesthesiology)
Care
Management
Events
1. Medication Error
Death or serious disability associated with a medication error (e.g., an error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
2. ABO-Incompatible Blood or Blood Product
Death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood product
3. Maternal Labor or delivery
Maternal death, loss of body part, disability, or loss of bodily function lasting more than seven days or still present at discharge associated with labor or delivery in a low-risk pregnancy while in a health care facility
4. Hypoglycemia
Death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is receiving care in a health care facility
5. Neonatal Hyperbilirubinemia
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in a neonate
6. Hospital-acquired Decubitus Ulcers
Stage III or IV pressure ulcers acquired after admission to a health care facility
7. Spinal Manipulative Therapy
Product or
Device
Events
1. Contaminated Drugs, devices, or biologics
Death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility
2. Unintended use or function of device
Death or serious disability associated with the use or function of a device that is other than the intended use or function.
3. Intravascular Air Embolism
Death or serious disability associated with intravascular air embolism that occurs while the patient is receiving care in a health care facility
Environmental
Events
1. Electric shock
Death or serious disability associated with an electric shock while patient is receiving care in a health care facility
2. Patient oxygen or gas line improperly designated
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
3. Burn while receiving care
Death or serious disability associated with a burn incurred while patient is receiving care in a health care facility
4. Fall of patient associated with death
Death associated with a fall while patient is receiving care in a health care facility
5. Use or lack of restraints or bedrails
Death or serious disability associated with the use of restraints or bedrails while patient is receiving care in a health care facility
Patient
Protection
Events
1. Infant Discharge to Wrong Person
2. Patient missing over 4 hours
Death or serious disability associated with a patient's disappearance for more than four hours
3. Patient suicide or attempted suicide
Suicide, or attempted suicide resulting in serious disability, while patient is receiving care in a health care facility
Criminal
Events
1. Instance of Care provided by impersonator
Any instance of care ordered or provided by someone impersonating a physician, nurse, pharmacist, or other health care provider
2. Abduction of Patient, any age
Abduction of a patient of any age
3. Sexual Assault of Patient
Sexual assault on a patient within or on the grounds of a health care facility
4. Physical Assault of Patient or Staff
Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) within or on the grounds of a health care facility
GLOSSARY OF TERMS – DEFINITIONS
Adverse
describes a negative consequence of care that results in unintended injury or illness, which may or may not have been preventable.
ASA Class I
ASA (American Society of Anesthesiologists) Class I patient refers to a normal, healthy patient, i.e., one who has no organic, physiological, biochemical, or psychiatric disturbance. The pathologic processes for which the operation is to be performed are localized and do not entail a systemic disturbance.
associated with
means that it is reasonable to assume initially that the adverse event was due to the referenced course of care; the unplanned event may be subject to further investigation and/or root cause analysis in order to confirm or refute the presumed relationship.
biologics
refers to therapeutics and products, including blood and vaccines, derived from living sources (such as humans, animals, and microorganisms).
device
refers to an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part or accessory, which is recognized in the official National Formulary, the U.S. Pharmacopeia, or any supplement to them; intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease; or intended to affect the structure or any function; and that does not achieve any of its primary intended purposes through chemical action and that is not dependent upon being metabolized for the achievement of any of its primary intended purposes. This includes items such as sutures, prepackaged procedure kits, Laerdal defibrillators, pacemakers, contact lenses, etc.
Disability
means a physical or mental impairment that substantially limits one or more of the major life activities of an individual.
Electrocution
is death by electric shock.
Error
is the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).
Event
means a discrete, auditable, and clearly defined occurrence
Health care facility
means any licensed facility that is organized, maintained, and operated for the diagnosis, prevention, treatment, rehabilitation, convalescence, or other care of human illness or injury, physical or mental, including care during and after pregnancy. Health care facilities include – but are not limited to – hospitals, nursing homes, rehabilitation centers, medical centers or offices, outpatient dialysis centers, reproductive health centers, independent clinical laboratories, hospices, and ambulatory surgical centers.
Hypoglycemia
is a physiologic state in which the blood sugar falls below 60 mg/dl and physiological and/or neurological dysfunction begins.
intended use
is the use of a device as described on the label and associated materials provided by the device's manufacturers.
kernicterus
refers to the medical condition in which elevated levels of bilirubin cause brain damage.
low-risk pregnancy
refers to a woman aged 18-39, with no previous diagnosis of essential hypertension, renal disease, collagen-vascular disease, liver disease, cardiovascular disease, placenta previa, multiple gestation, intrauterine growth retardation, smoking, pregnancy-induced hypertension, premature rupture of membranes, or other previously documented condition that poses a high risk of poor pregnancy outcome.
patient elopement
refers to any situation in which an admitted patient (i.e., inpatient) leaves the healthcare facility without staff being aware that the patient has done so.
preventable
describes an event that could have been anticipated and prepared against, but occurs because of an error or other system failure.
public accountability
is the obligation or duty of specific individuals and/or institutions to make information about their actions or performance available to the public or a public organization or agency (or its designee) that has responsibility for oversight and is answerable to the general public.
Serious
describes an event that results in death or loss of a body part, or disability or loss of bodily function lasting more than 7 days or that is still present at the time of discharge from an inpatient health care facility or, when referring to other than an adverse event, an event whose occurrence is not trivial.
spinal manipulative therapy
encompasses all types of manual techniques, including spinal mobilization (movement of a joint within its physiological range of motion) and manipulation (movement beyond its physiological range of motion), regardless of their precise anatomic and physiological focus or their discipline of origin.
toxic substances
refers to chemicals that are present in sufficient concentration to pose a hazard to human health.
Unambiguous
refers to an event that is clearly defined and easily identified.
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