Notification Adverse Events Notification Form Chapter 70

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					                                                            Adverse Events Notification Form
                                              Chapter 70.56 Adverse Health Events and Incident Reporting System


Please enter information in the gray-highlighted text box and submit this form to our office.
                                                                                                                                     For DOH use only:
Notification must be given to the department within 48 hours of event confirmation. You may save
this form or print out for your records after submitting to the department.
                                                                                                                         Notification method:
Facility Name:                                                                                                           Confirmation of event:

Facility Contact Name:                                                                                                   Confirmation sent:
                                                                                                                         RCA received:
Phone Number:
                                                                                                                         Database:
Contact Email:
                                                                                                                         Multiple same events:

Event Confirmation Date:

Event Type (number):

                                             Phone (24 hours/7 days): Adverse Events Hotline (888) 524-6257, or
                                      1
                                             Fax (24 hours/7 days): Adverse Events (360) 236-2830, or
                   Submit by:                Email: AdverseEventReporting@doh.wa.gov, or
                                             Mail form: DOH, Adverse Events, P.O. Box 47853, Olympia, WA 98504-7853


Surgical Events                                                                        Care Management Events cont’d
                                                                                            Patient death or serious disability associated with hypoglycemia, the onset
 1    Surgery performed on wrong body part                                             15
                                                                                            of which occurs while the patient is being cared for in a health care facility

                                                                                            Patient death or serious disability (kernicterus) associated with failure to
 2    Surgery performed on the wrong patient                                           16
                                                                                            identify and treat hyperbilirubinimia

                                                                                            Stage 3 or 4 pressure ulcers acquired after admission to a health care
 3    Wrong surgical procedure performed on a patient                                  17
                                                                                            facility

      Unintended retention of a foreign object in a patient after surgery or other
 4                                                                                     18   Patient death or serious disability due to spinal manipulative therapy
      procedure

      Intra-operative or immediately post-operative death in an ASA class 1
 5                                                                                     28   Artificial insemination with the wrong donor sperm or egg
      patient

Products or Devices                                                                    Environmental Events
      Patient death or serious disability associated with the use of contaminated           Patient death or serious disability associated with electric shock or elective
 6                                                                                     19
      drugs, devices, or biologics provided by the health care facility                     cardioversion while being cared for in a health care facility
      Patient death or serious disability associated with the use or function of a
                                                                                            Any incident in which a line designed for oxygen or other gas to be delivered
 7    device in patient care in which the device is used or functions other than as    20
                                                                                            to a patient contains the wrong gas or is contaminated by toxic substances
      intended
      Patient death or serious disability associated with intravascular air embolism        Patient death or serious disability associated with a burn incurred from any
 8                                                                                     21
      that occurs while being cared for in a health care facility                           source while being cared for in a health care facility

                                                                                            Patient death or serious disability associated with a fall while being cared for
Patient Protection Events                                                              22
                                                                                            in a health care facility

                                                                                            Patient death or serious disability associated with the use of restraints or
 9    Infant discharged to wrong person                                                23
                                                                                            bedrails while being cared for in a health care facility

      Patient death or serious disability associated with patient elopement
10
      (disappearance)                                                                  Criminal Events

      Patient suicide, or attempted suicide, resulting in serious disability, while         Any instance of care ordered by or provided by someone impersonating a
11                                                                                     24
      being cared for in a health care facility                                             physician, nurse, pharmacist, or other licensed health care provider

Care Management Events                                                                 25   Abduction of a patient of any age

      Patient death or serious disability associated with a medication error (e.g.
12    errors involving the wrong drug, wrong dose, wrong patient, wrong time,          26   Sexual assault on a patient within or on the grounds of a health care facility
      wrong rate, wrong preparation, or wrong route of administration
                                                                                            Death or significant injury of a patient or staff member resulting from a
      Patient death or serious disability associated with hemolytic reaction due to
13                                                                                     27   physical assault (i.e. battery) that occurs within or on the grounds of a health
      the administration of ABO/HLA-incompatible blood or blood products
                                                                                            care facility
      Maternal death or serious disability associated with hypoglycemia, the onset             For additional adverse event definitions please see the
14
      of which occurs while the patient is cared for in a health care facility                            National Quality Forum website.



HSQA/Office of Community Health Systems/Patient Safety-Adverse Events
DOH 689-004 (March 2011)

				
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