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NQF Adds 4 Serious Reportable Events, Updates 25

John Commins, for HealthLeaders Media, June 15, 2011
3. Patient protection events
  1. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
  2. Patient death or serious injury associated with patient elopement (disappearance)
  3. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting
4. Care management events
  1. 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)
  2. Patient death or serious injury associated with unsafe administration of blood products
  3. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
  4. (NEW) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
  5. Patient death or serious injury associated with a fall while being cared for in a healthcare setting
  6. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting
  7. Artificial insemination with the wrong donor sperm or wrong egg
  8. (NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
  9. (NEW) Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 
5. Environmental events
  1. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
  2. 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
  3. 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 healthcare setting
  4. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting
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