Hospital And Ambulatory Surgical Center Fax Report Form (Page 9 of 11) in pdf

SERIOUS REPORTABLE EVENT:

Is this a serious reportable incident (SRE) as defined by NQF ____ Yes ____No.

SRE TYPE: Indicate the type(s) of SRE below:

1. SURGICAL OR INVASIVE PROCEDURE EVENTS

___ Surgery or other invasive procedure performed on the wrong site

___ Surgery or other invasive procedure performed on the wrong patient

___ Wrong surgical or other invasive procedure performed on a patient

___ Unintended retention of a foreign object in a patient after surgery or other invasive procedure

___ Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient

2. PRODUCT OR DEVICE EVENTS

___ Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics

provided by the healthcare setting

___ 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

___ Patient death or serious injury associated with intravascular air embolism that occurs while being cared for

in a healthcare setting

3. PATIENT PROTECTION EVENTS

___ Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an

authorized person.

___ Patient death or serious injury associated with patient elopement (disappearance)

___ Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a

healthcare setting

4. CARE MANAGEMENT EVENTS

___ 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)

___ Patient death or serious injury associated with unsafe administration of blood products

___ Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being

cared for in a healthcare setting

___ Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

___ Patient death or serious injury associated with a fall while being cared for in a healthcare setting

___ Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a

healthcare setting

___ Artificial insemination with the wrong donor sperm or wrong egg

___ Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen

___ Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology,

or radiology test results

5. ENVIRONMENTAL EVENTS

___ Patient or staff death or serious injury associated with an electric shock in the course of a patient care

process in a healthcare setting

___ Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no

gas, the wrong gas, or are contaminated by toxic substances

___ 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

___ Patient death or serious injury associated with the use of physical restraints or bedrails while being cared

for in a healthcare setting

Hospital And Ambulatory Surgical Center Fax Report Form Page 9

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