TY - CHAP M1 - Book, Section TI - The National Quality Forum’s List of Serious Reportable Events, 2011 A1 - Wachter, Robert M. A1 - Gupta, Kiran PY - 2017 T2 - Understanding Patient Safety, 3e AB - Surgical or invasive procedure events (n = 5)Surgery or other invasive procedure performed on the wrong siteSurgery or other invasive procedure performed on the wrong patientWrong surgical or other invasive procedure performed on a patientUnintended retention of a foreign object in a patient after surgery or other invasive procedureIntraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patientProduct or device events (n = 3)Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare settingPatient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intendedPatient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare settingPatient protection events (n = 3)Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized personPatient 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 settingCare management events (n = 9)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 productsMaternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare settingDeath or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy (new in 2011)Patient death or serious injury associated with a fall while being cared for in a healthcare settingAny Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare settingArtificial insemination with the wrong donor sperm or wrong eggPatient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen (new in 2011)Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results (new in 2011)Environmental events (n = 4)Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare settingAny incident in which systems designated for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas, or are contaminated by toxic substancesPatient 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 settingPatient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare settingRadiologic events (n = 1)Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area (new in 2011)Potential criminal events (n = 4)Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare providerAbduction of a patient/resident ... SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/28 UR - accessmedicine.mhmedical.com/content.aspx?aid=1146176748 ER -