New Jersey Department of Health

Report of Serious Preventable

Adverse Event	NJDoh Internal use only
Report No.
This form must be completed for any serious preventable adverse event. All information is protected based on the provisions of the Patient Safety Act [N.J.S.A. 26:2H-12.25(f)]

Is this a revision of an earlier report to the Patient Safety Initiative for the same event?

Yes	No	If yes, give NJDOH Report Number:

Facility Internal Tracking Number of this event, if known:

SECTION A - GENERAL INFORMATION
1. FACILITY IDENTIFICATION
Facility Name:	Facility License No.:
Facility Street Address:	County:
City:	State:	Zip Code:
Name of Person Submitting:	Telephone No.:
Title or Position:	Fax No.:
Email Address:

2. PLEASE SUPPLY A BRIEF DESCRIPTION (2 TO 3 SENTENCES) OF THE EVENT OR SITUATION YOU ARE REPORTING:
Event Information:
Event Date:	Time:	AM	PM
Date Event Discovered:	Time:	AM	PM

3. How was event discovered? (check only one)
1. Report by staff/physician	4. Assessment of patient/resident after event
2. Report by family/visitor	5. Review of chart/record
3. Report by patient/resident	6. Other:
4. PATIENT/RESIDENT INFORMATION
Inpatient	or	Outpatient
Admission through:	Emergency	Direct	Transfer from Acute	Transfer from LTC
Department	Admission	Care General Hospital	or Assisted Living
Patient/Resident Billing Number:
Patient/Resident Name:	Medical Record No.:
Street Address:	County:
City:	State:	Zip Code:
Date of Birth:	Gender:
Admission Date or Date of Ambulatory Encounter:
Admission Diagnosis:
Race:
Caucasian	Amer. Indian/Alaskan Native	Native Hawaiian/Pacific Islander	Other:
Black	Asian	Unable to Determine
Ethnicity:
Non-Hispanic/Unable to Determine	Hispanic
SECTION B - EVENT DETAILS
5. TYPES OF SERIOUS PREVENTABLE ADVERSE EVENTS (Check only one)
A. CARE MANAGEMENT EVENTS in a Health Care Facility

1.	Patient/resident death/harm due to a medication error

2.	Patient/resident death/harm due to a hemolytic reaction due to the administration of ABO-incompatible blood or blood products

3.	Maternal death/harm due to labor/delivery in a low-risk pregnancy

4.	Patient/resident death/harm due to hypoglycemia

5.	Patient/resident death/harm due to failure to identify and treat hyperbilirubinemia in neonates

6.	Stage 3 or 4 pressure ulcers acquired after admission (excludes progression from Stage II to Stage III if Stage II was recognized and documented upon admission)

7.	Patient/resident death/harm due to spinal manipulative therapy

8.	Other event causing patient/resident death or harm that lasts seven days or is present at discharge

B. ENVIRONMENTAL EVENTS in a Health Care Facility

1.	Patient/resident death/harm due to an electric shock

2.	Any event in which a line designated for oxygen/other gas to be delivered to a patient/resident contains the wrong gas or is contaminated by toxic substances

3.	Patient/resident death/harm due to a burn incurred from any source

4.	Patient/resident death/harm due to a fall

5.	Patient/resident death/harm due to the use of restraints or bedrails

6.	Other event causing patient/resident death or harm that lasts seven days or is present at discharge

C. PRODUCT OR DEVICE EVENTS in a Health Care Facility

1.	Patient/resident death/harm due to the use of contaminated drugs/devices/biologics

2.	Patient/resident death/harm due to the use/function of a device in patient/resident care in which the device is used/functions other than as intended

3.	Patient/resident death/harm due to intravascular air embolism

4.	Patient/resident death/harm due to the use of a single‑use device in which the device is used/functions other than as intended:

new single-use device

reprocessed single-use device

5.	Other event causing patient/resident death or harm that lasts seven days or is present at discharge

D. SURGERY-RELATED EVENTS

1.	Surgery performed on the wrong body part

2.	Surgery performed on the wrong patient

3.	Wrong surgical procedure performed on a patient

4.	Retention of a foreign object in a patient after surgery or other procedure

5.	Intraoperative or post-operative (i.e., within 24 hours) coma, death or other serious preventable adverse event for an ASA Class I inpatient or for any ASA Class same day surgery patient or outpatient (includes situations where anesthesia was administered)

6.	Other event causing patient death or harm that lasts seven days or is present at discharge

E. PATIENT/RESIDENT PROTECTION EVENTS in a Health Care Facility

1.	Infant discharged to the wrong person

2.	Patient/resident death/harm due to patient elopement

3.	Patient/resident suicide/attempted suicide

4.	Other event causing patient/resident death or harm that lasts seven days or is present at discharge

6. IF 5.A.1 WAS SELECTED, COMPLETE THIS SECTION:
What type of medication error occurred? (Check all that apply)

Administration After Order Discontinued/Expired	Wrong Drug

Monitoring Error	Wrong Frequency

Omission	Wrong Patient

Wrong Diluent/Concentration/Dosage Form	Wrong Route

Wrong Dose	Wrong Time
Other:
Brand/Product Name (If Applicable):
Generic Name:
7. WHERE WAS THE PATIENT/RESIDENT WHEN THE EVENT OCCURRED? (Check all that apply)
Cardiac Catheterization Laboratory

Emergency Department

Emergency Department Crisis Screening/Observation

Hallway/Common Area

In Transit

Laboratory

NICU

Nursery

Operating Room

PACU

Procedure Room

Radiology

Rehabilitation Areas

Other:	Patient Room (Check Unit below)

Patient Bathroom (Check Unit below)

Units

Med/Surg

ICU/CCU/TCU

Step Down

Telemetry

Labor/Delivery

Behavioral Health

8A. IMMEDIATE CLINICAL ACTION(S) TAKEN FOR THE PATIENT:

8B. IMMEDIATE CORRECTIVE ACTIONS TO PREVENT FUTURE SIMILAR EVENTS:

New Jersey Department of Health

Report of Serious Preventable

Adverse Event

Continued	NJDoH Internal use only
Report No.

HCQ-1

AUG 12	Page 2 of 3 Pages.

AUG 12	Page 1 of 3 Pages.

HCQ-1, Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility

HCQ-1, Report of Serious Preventable Adverse Event, New Jersey Licensed Health Care Facility, reporting, health care quality, HCQ, HCQO-19

EWHITE

2009-09-09

NJDOH