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– GEORGIA –
Public and Private Policy
Medical Errors and Patient Safety

Definitions

  • •  Hospital Definitions

    Georgia has two sets of definitions for reportable 'patient incidents' vs. 'sentinel events' for hospitals. The GHA-sponsored Partnership for Health and Accountability (PHA) program that began in 2000 requires a separate list of reportable events [adapted from JCAHO's Reviewable Sentinel Events that are reported as part of the PHA's Accountability and Health Safety (A&HS) Committee definitions [PDF].

    Mandatory reporting of ‘Patient incidents’ began March 12, 2003 with the Department of Human Resources rules for hospitals. Initially only 7 events (including 3 environmental events) were required, but by December 12, 2005, a total of 14 discrete events must be reported. The ORS provides some assistance with interpretation and reporting via their FAQ website. In addition The table below provides the links to the interpretive assistance and reveals the partial mismatch between the two lists.

    The PHA program adopts JCAHO's reviewable events that are subject to review according to the Joint Commission's Sentinel Event Policy. There is duplication of reporting of 6 events between the two programs (unanticipated death, injury with loss of function, rape, surgery – wrong patient, surgery – wrong site, and discharge of infant to wrong family). The differences in definitions for rape, injury with loss of function, and unanticipated death likely would identify slightly different cohorts of patients.

– Comparison of Definitions –
GHA-sponsored PHA Program vs.
Georgia Department of Human Resources (DHR) Regulations

Definitions adapted from:
1.  JCAHO's ‘Reportable Sentinel Events
2.  GHA-sponsored Partnership for Health and Accountability (PHA): ‘Sentinel Events’ [PDF]
3.  Department of Human Resources (DHR): Hospital ‘Patient Incidents’ [OCRR § 290-9-7-.07(2)]
Hospital Definitions
PHA | DHR
Source/Link
Definition Text
Sentinel Event
-- -- JCAHO
A Sentinel Event is an event that resulted in an unanticipated death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
1 -- PHA [PDF]
A Sentinel Event is an event that resulted in an unanticipated death or serious physical or psychological injury. Serious injury specifically includes loss of limb or function. [Different definition from JCAHO]
Unanticipated Death
-- -- JCAHO
. . .is an event that resulted in an unanticipated death . . .
2. -- PHA [PDF]
. . . is an event that resulted in an unanticipated death . . .[Definition identical to JCAHO]
-- 1. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(i)
Any unanticipated patient death not related to the natural course of the patient's illness or underlying condition; The ORS provides decision-tree guidelines to assist in identifying these patients. [PDF]
Injury – Loss of Limb
-- -- JCAHO
. . .is an event that resulted in serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb . . . The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. [PHA does not include this portion of JCAHO definition]
-- 2. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(I)
Any patient injury which is unrelated to the patient's illness or underlying condition and results in a permanent loss of limb or function,
Injury – Loss of Function
-- -- JCAHO
. . .is an event that resulted in serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of . . . function . . The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
3. -- PHA [PDF]
. . . is an event that resulted in . . . serious physical or psychological injury. Serious injury specifically includes loss . . . of function. . .
-- 3. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(I)
Any patient injury which is unrelated to the patient's illness or underlying condition and results in a permanent loss of . . . function
Rape
-- -- JCAHO
Reviewable Sentinel Event
Rape, as a reviewable sentinel event, is defined as unconsented sexual contact involving a patient and another patient, staff member, or unknown perpetrator while being treated or on the premises of the health care organization, including oral, vaginal or anal penetration or fondling of the patient's sex organ(s) by another individual's hand, sex organ or object. One or more of the following must be present to determine reviewability:
  • •  Any staff witnessed sexual contact as described above
  • •  Sufficient clinical evidence obtained by the organization to support allegations of unconsented sexual contact
  • •  Admission by the perpetrator that sexual contact, as described above, occurred on the premises.
4. -- PHA [PDF]
Rape [Definition not further clarified]
-- 4. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(II)
Any rape which occurs in a hospital;
The Office of Regulatory Services (ORS) provides decision-tree guidelines to assist in identifying any allegedly raped patient. [PDF]
Surgery - Wrong Patient
5. -- PHA [PDF]
(5) Surgery on the wrong patient or wrong body part
-- 5. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(II)
Any surgery on the wrong patient or the wrong body part of the patient;
The DHR provides decision-tree guidelines to assist in identifying these patients. [PDF]
Surgery - Wrong Body Part
6. -- PHA [PDF]
(5) Surgery on the wrong patient or wrong body part
-- 6. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(II)
Any surgery on the wrong patient or the wrong body part of the patient;
The DHR provides decision-tree guidelines to assist in identifying these patients. [PDF]
Infant Discharge to Wrong Family
7. -- PHA [PDF]
Infant abduction or discharge to the wrong family
-- 7. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(IV)
Discharge of an infant to the wrong family [Identical to PHA definition]
Infant Abduction
8. -- PHA [PDF]
Infant abduction or discharge to the wrong family [Not included in DHR events and definition is different from JCAHO Reviewable Sentinel Event.]
Suicide
9. -- PHA [PDF]
(1) Suicide of a patient in a setting where the patient received around the clock care (e.g., hospitals, residential treatment center, crises stabilization center), . . . even if the outcome was not death or major permanent loss of function. [Definition is identical to JCAHO]
Transfusion Reaction
10. -- PHA [PDF]
(4) Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
Burn
  8. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(II)
Second or third degree burns involving twenty (20) percent or more of the body surface of an adult patient or fifteen (15) percent or more of the body surface of a child which burns were acquired by the patient in the hospital,
Equipment Malfunction / Misuse
-- 9. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(III)
Serious injury to a patient resulting from the malfunction or intentional or accidental misuse of patient care equipment,
Patient Missing >8-Hours
-- 10. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(V)
Any time an inpatient, or a patient under observation status, cannot be located, where there are circumstances that place the health, safety, or welfare of the patient or others at risk and the patient has been missing for more than eight (8) hours
Assault of Patient
-- 11. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(a)1(iv)(VI)
Any assault on a patient, which results in an injury that requires treatment.
Environmental Event – Labor Strike
-- 12. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(b)1(i)
Other Events/Incidents Requiring Report: A labor strike, walk-out, or sick-out
Environmental Event – External Disaster
-- 13. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(b)1(ii)
Other Events/Incidents Requiring Report: An external disaster or other community emergency situation
Environmental Event – Utilities/Services Failure
-- 14. DHR Hospital Rule
OCCR § 290-9-7-.07(2)(b)1(iii)
Other Events/Incidents Requiring Report: An interruption of services vital to the continued safe operation of the facility, such as telephone, electricity, gas, or water services.
10 14
Total Number of Events by Program

The Department of Human Resources rules and regulations were effective on December 12, 2002. [Chapter 290-9-7-.07(2)(a)] Reporting of the first three types of patient incidents began 90 days after the initial effective date of the rules and regulations ( March 12, 2003). Reporting of siix additional types of patient incidents to the Department were required to begin no later than December 12, 2005.

In addition to reportable incidents, the voluntary PHA program also includes reporting of 'near-misses'.

  • •  Dialysis Unit and Clinical Laboratory Definitions

    The Department of Human Services has separate definitions in the rules for End-Stage Renal Dialysis (ESRD) facilities and for Clinical Laboratories. Five of the 7 definitions for ESRD facilities are unique to ESRD facilities; only ‘unanticipated death’ and ‘equipment malfunction | misuse’ are common with reportable hospital events.

    Of the 3 reportable clinical lab events, the ‘transfusion’ event is similar to the PHA event, and the ‘Environmental event / utility failure’ is similar to the DHR event definition for hospitals.

    The ESRD Incident Reporting Form [PDF] and instructions for completing it are available. Hospital Reporting Forms are available for environmental events [PDF], while ‘Patient Incidents’ [PDF] and the instructions to complete them [PDF] are outdated and do not include all events that are reportable by December 12, 2005. Clinical laboratory incident reporting forms are unavailable in early 2006.

End-Stage Renal Dialysis Facility Definitions
No.
Source/Link
Definition Text
Unanticipated Death
1. DHR ESRD Rule
OCCR § 290-9-9-.07(c)1
Any unanticipated patient death not related to the natural course of the illness or the patient's underlying condition occurring at the facility or as a direct result of treatment received in the facility. This event applies to patients receiving dialysis services through the facility.
Malfunction | Misuse of Equipment
2. DHR ESRD Rule
OCCR § 290-9-9-.07(c)2
Any serious injury resulting from the malfunction or intentional or accidental misuse of patient care equipment. This event applies to patients receiving dialysis services through the facility.
Exsanguination
3. DHR ESRD Rule
OCCR § 290-9-9-.07(c)3
Exsanguination while at the facility. This event applies to patients receiving dialysis services through the facility.
Use of Another Patient's dialyzer
4. DHR ESRD Rule
OCCR § 290-9-9-.07(c)4
Any patient dialyzed with another patient'ss dialyzer where the facility reuses the hemodialyzers. This event applies to patients receiving dialysis services through the facility.
Prescription Problem
5. DHR ESRD Rule
OCCR § 290-9-9-.07(c)5
Any deviation in fulfilling the patient prescription which results in a significant adverse patient outcome.. This event applies to patients receiving dialysis services through the facility.
Sexual Assault
6. DHR ESRD Rule
OCCR § 290-9-9-.07(c)6
Any sexual or physical assault of or by a patient which is alleged to have occurred in the facility. This event applies to patients receiving dialysis services through the facility.
Physical Assault
7. DHR ESRD Rule
OCCR § 290-9-9-.07(c)6
Any sexual or physical assault of or by a patient which is alleged to have occurred in the facility. This event applies to patients receiving dialysis services through the facility.
 
Clinical Laboratory Definitions
Transfusion Reaction | Death
1. DHR ESRD Rule
OCCR § 290-9-8-.27(3)(a)
Fatal transfusion reactions or transfusion complications affecting the patients
Lab Test Error
2. DHR ESRD Rule
OCCR § 290-9-8-.27(3)(b)
Laboratory testing errors which have resulted in the death or serious injury of a patient or employee
Environmental Event - Interuption of Utilities | Services
3. DHR ESRD Rule
OCCR § 290-9-8-.27(3)(c)
Significant interruptions in service vital to the continued safe operation of the facility, such as the loss of electricity, gas or water services
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