3.24.2016

Report on Medical Errors at NH Hospitals

A series of articles on the reporting of adverse events — serious medical errors also known as "never events" — by NH hospitals is available at: InDepthNH.org. There are 29 types of errors — all considered to be avoidable mistakes — that hospitals must report to the Department of Health and Human Services. (See the full list below.)

The most recent data from 2014, shows 73 never events were reported. These include 25 patient falls and 22 pressure ulcers, as well as 14 surgery-related errors at NH hospitals including Catholic Medical Center, Concord Hospital, Mary Hitchcock Memorial Hospital, and Portsmouth Regional Hospital.

How did your hospital do? See the full public document listing the type of adverse events reported by each NH hospital at this NHDHHS web page.

What Are Never Events?

Here is the list of 29 adverse events that hospitals in NH must report in an effort to reduce medical errors and improve patient safety, as reported by Nancy West at InDepthNH.org
Surgical or invasive procedure events
  • Surgery or other invasive procedure performed on the wrong site
  • Surgery or other invasive procedure performed on the wrong patient
  • Wrong surgical or other invasive procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other invasive procedure
  • Intraoperative or immediately postoperative/post procedure death in an ASA Class 1 patient
Product or device events
  • Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting
  • Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  • Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting
Patient protection events
  • Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
  • Patient 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 setting
Care management events
  • 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 products
  • Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
  • Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
  • Patient death or serious injury associated with a fall while being cared for in a healthcare setting
  • Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting
  • Artificial insemination with the wrong donor sperm or wrong egg (updated)
  • Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
  • Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
Environmental events
  • Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
  • Any 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 substances
  • Patient 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 setting
  • Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting
Radiologic events
  • Death or serious injury of a patient or staff associated with the introduction of a metallic object into the M RI area
Potential 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/resident of any age
  • Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
  • Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting

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