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Illinois 34 Reportable Adverse Events and Outcomes

Adverse Events were collected from Outcome measures were collected from
No. and Type Event Title Description of Event
Surgical Events
1 Surg1 Wrong Body Part Surgery performed on the Wrong Body Part that is not consistent with the documented informed consent for that patient. Reportable events under this clause do not include situations requiring prompt action that occur in the course of surgery or situations whose urgency precludes obtaining informed consent.
2 Surg2 Wrong Patient Surgery performed on the wrong patient
3 Surg3 Wrong Procedure Wrong surgical procedure performed on a patient that is not consistent with the documented informed consent for that patient. Reportable events under this clause do not include situations requiring prompt action that occur in the course of surgery or situations whose urgency precludes obtaining informed consent.
4 Surg4 Retained Foreign Body Retention of a foreign object in a patient after surgery or other procedure, excluding objects intentionally implanted as part of a planned intervention and objects present prior to surgery that are intentionally retained.
5 Surg5 Unexpected Surgical Death Death during or immediately after surgery of a normal, healthy patient who has no organic, physiologic, biochemical, or psychiatric disturbance and for whom the pathologic processes for which the operation is to be performed are localized and do not entail a systemic disturbance.
Product or Device Events
6 Prod1 Contaminated Drugs/Products Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility when the contamination is the result of generally detectable contaminants in drugs, devices, or biologics regardless of the source of the contamination or the product.
7 Prod2 Product/Device Malfunction 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. "Device" includes, but is not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators.
8 Prod3 Intravascular air embolism Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.
Patient Protection Events
9 Protect1 Discharge to Wrong Person Infant discharged to the wrong person
Illinois regulations for hospitals independently require reporting of children who are not discharged to a "natural parent" and/or who do not meet criteria [77 Ill. Admin. Code §250.1840].
10 Protect2 Patient Disappearance Patient death or serious disability associated with patient disappearance for more than 4 hours, excluding events involving adults who have decision-making capacity.
11 Protect3 Patient Suicide Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a health care facility due to patient actions after admission to the health care facility, excluding deaths resulting from self-inflicted injuries that were the reason for admission to the health care facility.
Care Management Events
12 CareMan1 Medication Error Patient death or serious disability associated with a medication error, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose. Excludes reasonable differences in clinical judgment on drug selection and dose.
13 CareMan2 Hemolytic Blood Reaction Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products.
14 CareMan3 Maternal Obstetric Death Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility, excluding deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.
Illinois hospital regulations also require reporting of any death of any woman dying of any cause whatsoever while pregnant . . . [AE #25]
15 CareMan4 Hypoglycemia Patient death or serious disability directly related to hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility for a condition unrelated to hypoglycemia.
The following 3 NQF ‘Care Management Events’ are Not Included in Illinois Definitions
Neonatal Hyperbilirubinemia Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in a neonate
New Decubitus Ulcer Stage III or IV pressure ulcers acquired after admission to a health care facility
Spinal Manipulation Death or serious disability due to spinal manipulative therapy
Environmenta Events
16 Envir1 Electrical shock Patient death or serious disability associated with an electric shock while being cared for in a health care facility, excluding events involving planned treatments such as electric countershock.
17 Envir2 Wrong Gas Delivered 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.
18 Envir3 Patient Burn Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility that is not consistent with the documented informed consent for that patient. Reportable events under this clause do not include situations requiring prompt action that occur in the course of surgery or situations whose urgency precludes obtaining informed consent.
19 Envir4 Fall Patient death associated with a fall while being cared for in a health care facility.
20 Envir5 Restraints / Bedrails Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.
Physical Security Events
21 PhysSec1 Impersonating Professionals Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
22 PhysSec2 Abduction Abduction of a patient of any age
23 PhysSec3 Sexual Assault Sexual assault on a patient within or on the grounds of a health care facility
24 PhysSec4 Physical Assault Death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a health care facility
Illinois-Specific Events
25 IllSpecEv1 Maternal Death during Pregnancy Maternal Death is the death of any woman dying of any cause whatsoever while pregnant [77 Ill. Admin. Code §657.10]. Because the death is reported "regardless of whether the death occurred in the maternity division or any other section of the hospital, or whether the patient was delivered in the hospital where death occurred, or elsewhere," this definition is regarded as separate and distinct from the similar definition provide by the NQF in AE#14.
26 IllSpecEv2 Death following Aborted pregnancy Maternal Death is the death of any woman dying of any cause whatsoever . . . within one year after the termination of the pregnancy, irrespective of the duration of the pregnancy at the time of the termination or the method by which it was terminated [77 Ill. Admin. Code §657.10]. A death shall be reported regardless of whether the death occurred in the maternity division or any other section of the hospital, or whether the patient was delivered in the hospital where death occurred, or elsewhere.
27 IllSpecEv3 Incident due to Natural catastrophe Any incident or occurrence in a hospital that could be considered a catastrophe or creates an immediate jeopardy and/or dangerous threat and that requires the transfer of patients to other parts of the facility or other facilities, including but not limited to fire, flood, or power failure, shall be reported to the Department within two working days after its occurrence. [77 Ill. Admin. Code §250.1520(f)]
28 IllSpecEv4 Incident due to Fire
29 IllSpecEv5 Incident due to System Failure
Illinois-Specific Outcomes
30 IllSpecOut1 Risk-adjusted Mortality Rate As mandated by the Hospital Report Card Act of 2004, the Department shall also publish risk-adjusted mortality rates for each hospital. [210 ILCS 86/30]
31 IllSpecOut2 Nursing Staffing As mandated by the Hospital Report Card Act of 2004, the Department shall prepare quarterly reports reporting nursing hours per patient day, average daily census, and average daily hours worked for each clinical service area. [210 ILCS 86/25(a)(1)]
32 IllSpecOut3 Hospital-acquired Infection – Surgical Wound Infection As mandated by the Hospital Report Card Act of 2004, the Department shall prepare quarterly reports for Class I Surgical Site Nosocomial infection rates for the facility for the specific clinical procedures determined by the Department by rule. [210 ILCS 86/25(a)(2)(A)]
33 IllSpecOut4 Hospital-acquired Infection – Ventilator-assisted Pneumonia As mandated by the Hospital Report Card Act of 2004, the Department shall prepare quarterly reports for Ventilator-assisted Pneumonia nosocomial infection rates for the facility for the specific clinical procedures determined by the Department by rule. [210 ILCS 86/25(a)(2)(B)]
34 IllSpecOut5 Hospital-acquired Infection – Central line-related bloodstream infections As mandated by the Hospital Report Card Act of 2004, the Department shall prepare quarterly reports for Central line-related bloodstream nosocomial infection rates for the facility for the specific clinical procedures determined by the Department by rule. [210 ILCS 86/25(a)(2)(C)]
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