Section 151:38 Hospitals and Ambulatory Surgical Centers Required to Report Adverse Events.
I. Any hospital or ambulatory surgical center licensed pursuant to this chapter shall report to the commissioner the occurrence of any of the adverse health care events described in subparagraphs (a)-(f) as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards. Events to be reported under this subdivision include:
(a) Surgical events including:
(1) Surgery performed on a wrong body part that is not consistent with the documented informed consent for that patient. Reportable events under this subparagraph do not include situations requiring prompt action that occur in the course of surgery or situations where urgency precludes obtaining informed consent.
(2) Surgery performed on the wrong patient.
(3) The wrong surgical procedure performed on a patient that is not consistent with the documented informed consent for that patient. Reportable events under this subparagraph do not include situations requiring prompt action that occur in the course of surgery or situations where urgency precludes obtaining informed consent.
(4) 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) 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.
(b) Product or device events including:
(1) Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the 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.
(2) 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.
(3) Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.
(c) Patient protection events including:
(1) An infant discharged to the wrong person.
(2) Patient death or serious disability associated with patient disappearance, excluding events involving adults who have decision-making capacity.
(3) Patient suicide or attempted suicide resulting in serious disability while being cared for in a facility due to patient actions after admission to the facility, excluding deaths resulting from self-inflicted injuries that were the reason for admission to the facility.
(d) Care management events including:
(1) 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.
(2) Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products.
(3) Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a facility, including events that occur within 42 days postdelivery and excluding deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.
(4) Patient death or serious disability directly related to hypoglycemia, the onset of which occurs while the patient is being cared for in a facility.
(5) Death or serious disability, including kernicterus, associated with failure to identify and treat hyperbilirubinemia in neonates during the first 28 days of life. ""Hyperbilirubinemia'' means bilirubin levels greater than 30 milligrams per deciliter.
(6) Stage 3 or 4 ulcers acquired after admission to a facility, excluding progression from stage 2 to stage 3 if stage 2 was recognized upon admission.
(7) Patient death or serious disability due to spinal manipulative therapy.
(8) Artificial insemination with the wrong donor sperm or wrong egg.
(e) Environmental events including:
(1) Patient death or serious disability associated with an electric shock while being cared for in a facility, excluding events involving planned treatments such as electric countershock.
(2) 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.
(3) Patient death or serious disability associated with a burn incurred from any source while being cared for in a facility.
(4) Patient death or serious disability associated with a fall while being cared for in a facility.
(5) Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility.
(f) Criminal events including:
(1) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
(2) Abduction of a patient of any age.
(3) Sexual assault on a patient within or on the grounds of a facility.
(4) Death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.
II. Following the occurrence of an adverse health care event, the facility shall conduct a root cause analysis of the event. Following the analysis, the facility shall implement a corrective action plan to implement the findings of the analysis or report to the commissioner any reasons for not taking corrective action. If the root cause analysis and the implementation of a corrective action plan are complete at the time an event must be reported, the findings of the analysis and the corrective action plan shall be included in the report of the event. The findings of the root cause analysis and a copy of the corrective action plan shall otherwise be filed with the commissioner within 60 days of the event.
III. All information and data made available to the department and its designees under this section shall be confidential and shall be exempt from public access under RSA 91-A.
Source. 2009, 287:2, eff. Jan. 1, 2010.