Air Embolism

Cause Mapping method of Root Cause Analysis - Health Care Examples

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Never Events

The National Quality Forum (NQF) developed the list of "never events" below with support from the Centers for Medicare & Medicaid Services' (CMS) . To be included on NQF's list of "never events", an event had to have been characterized as: unambiguous, usually preventable, and serious.


Surgical Events

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure on a patient
• Retention of a foreign object after surgery or other procedure
• Intraoperative or immediately post-operative death in a normal health patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative)

Product or Device Events

• Patient death or serious disability associated with use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or seriously disability associated with the use or function of a device in patient care in which the device is used or functions other than intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient elopement (disappearance) for more than four hours
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events

• Patient death or serious disability associated with a medication error
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products
• Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy

Environmental Events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• 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 substance
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual asssault on a patient within or on the grounds of a healthcare facility
• Death or significant injury of a patient or a staff member resulting from a physical assault (i.e. battery) that occurs within or on the grounds on a healthcare facility
  

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