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Adverse health events.

The National Quality Forum identifies and defines twenty-nine serious reportable events. The twenty-nine adverse health events described in the National Quality Forum 2011 update are listed in WAC 246-302-030.
(1) Surgical or invasive procedure events:
(a) Surgery or other invasive procedure performed on the wrong site.
(b) Surgery or other invasive procedure performed on the wrong patient.
(c) Wrong surgical or other invasive procedure performed on a patient.
(d) Unintended retention of a foreign object in a patient after surgery or other invasive procedure.
(e) Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient.
(2) Product or device events:
(a) Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting.
(b) Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.
(c) Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting.
(3) Patient protection events:
(a) Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.
(b) Patient death or serious injury associated with patient elopement (disappearance).
(c) Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a health care setting.
(4) Care management events:
(a) Patient death or serious injury 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).
(b) Patient death or serious injury associated with unsafe administration of blood products.
(c) Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting.
(d) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.
(e) Patient death or serious injury associated with a fall while being cared for in a health care setting.
(f) Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a health care setting.
(g) Artificial insemination with the wrong donor sperm or wrong egg.
(h) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen.
(i) Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.
(5) Environmental events:
(a) Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a health care setting.
(b) Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances.
(c) Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting.
(d) Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a health care setting.
(6) Radiologic events: The death or serious injury of a patient or staff associated with the introduction of a metallic object into the magnetic resonance imaging (MRI) area.
(7) Potential criminal events:
(a) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
(b) Abduction of a patient/resident of any age.
(c) Sexual abuse/assault on a patient or staff member within or on the grounds of a health care setting.
(d) Death or serious 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 setting.
[Statutory Authority: Chapter 70.56 RCW. WSR 12-16-057, ยง 246-302-030, filed 7/30/12, effective 10/1/12.]
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