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Connecticut 33 Reportable Adverse Events

(Modified from NQF 27 Serious reportable Events in Health Care and Connecticut Adverse Event Reporting Form [PDF])
Event No. / Type Description of Event
Surgical Events
1 1A Surgery performed on the Wrong Body Part
Defined as any surgery performed on a body part that is not consistent with the documented informed consent for that patient.

Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent.

Surgery includes endoscopies and other invasive procedures.
2 1B Surgery performed on the wrong patient
Defined as any surgery on a patient that is not consistent with the documented informed consent for that patient.

Surgery includes endoscopies and other invasive procedures.
3 1C Wrong surgical procedure performed on a patient
Defined as any procedure performed on a patient that is not consistent with the documented informed consent for that patient.

Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent.

Surgery includes endoscopies and other invasive procedures.
4 1D Retained Foreign Body
Retention of a foreign object in a patient after surgery or other procedure. Excludes objects intentionally implanted as part of a planned intervention and objects present prior to surgery that were intentionally retained.
5 1E Death of health patient
Intraoperative or immediate post-operative death in an ASA (American Society of Anesthesiology) Class I patient. Includes all ASA Class I patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out.

Immediately post-operative means within 24 hours after induction of anesthesia (if surgery not completed), surgery, or other invasive procedure was completed.
Product or Device Events
6 2A Contaminated drugs, devices, or biologics
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility. Includes generally detectable contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product.
7 2B Unintended use or function of device
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. Includes, but is not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators.
8 2C Intravascular Air Embolism
Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility. Excludes deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.
Patient Protection Events
9 3A Infant discharged to the wrong person
10 3B Patient Missing over 4 hours
Patient death or serious disability associated with patient elopement (disappearance) for more than four hours. Excludes events involving competent adults.
11 3C Patient suicide or attempted suicide
Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility. Defined as events that result from patient actions after admission to a healthcare facility.

Excludes deaths resulting from self-inflicted injuries that were the reason for admission to the healthcare facility.
Care Management Events
12 4A Medication Error
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). Excludes reasonable differences in clinical judgment on drug selection and dose.
13 4B ABO-incompatible Blood or blood products
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products
14 4C Maternal Labor or delivery
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility. Includes events that occur within 42 days post-delivery.

Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy or cardiomyopathy.
15 4D Hypoglycemia
Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
16 4E Neonatal Hyperbilirubinemia
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates. Hyperbilirubinemia is defined as bilirubin levels >30mg/dl.

Neonates refers to the first 28 days of life.
17 4F Hospital-acquired Decubitus Ulcers
Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility. Excludes progression from Stage 2 to Stage 3, if Stage 2 was recognized upon admission.
18 4G Spinal Manipulative Therapy
Patient death or serious disability due to spinal manipulative therapy
Environmenta Events
19 5A Electric Shock
Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility. Excludes events involving planned treatments such as electric countershock.
20 5B Patient oxygen or gas line improperly designated
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
21 5C Burn while receiving care
Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
22 5D Fall of patient associated with death
Patient death associated with a fall while being cared for in a healthcare facility
23 5E Use or lack of restraints or bedrails
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
Criminal Events
24 6A Instance of Care provided by impersonator
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
25 6B Abduction of a patient of any age
26 6C Sexual Assault of Patient
Sexual assault on a patient within or on the grounds of a healthcare facility
27 6D Physical Assault of Patient or Staff
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 healthcare facility
Connecticut Specific Events
28 7A Perforation during procedure
Perforations during open, laparoscopic and/or endoscopic procedures resulting in death or serious disability. Includes perforations which require resection.
29 7B Falls causing disabillity
Falls resulting in serious disability while being cared for in a healthcare facility. Includes fractures and/or head injuries with intracranial hemorrhage.
30 7C Death of Neonate
Obstetrical events resulting in death or serious disability to the neonate
31 7D Medication Reactions
Significant medication reactions resulting in death or serious disability. Includes medication reactions, anaphylaxis, or development of methemoglobinemia following use of anesthetic spray.
32 7E Unreported Lab / X-ray result in Emergency Room
Laboratory or radiologic test results not reported to the treating practitioner or reported incorrectly which result in death or serious disability due to incorrect or missed diagnosis in the emergency department.
33 7F Nosocomial Infections
Nosocomial infections defined as reportable sentinel events by the Joint Commission on Accreditation of Healthcare Organizations.. All identified cases of death and major permanent loss of function attributed to a nosocomial infection (i.e. except for the infection, the patient probably would not have died or suffered major permanent loss of function.)
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