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.