Adverse Event Resources

• Chapter 70.56 RCW Adverse health events and incident reporting system
• List of Adverse Events and definitions
(239 KB PDF)
• Full NQF Adverse Event 2006 Update
(975 KB PDF)
• Guide: Reporting an adverse event
(317 KB PDF)
• Guide: Root Cause Analysis process (52 KB PDF)
• Guide: Reporting Aggregate Reviews
(127 KB PDF)
• Adverse Events Quarterly Reports
• Facility Quarterly Check-in-Survey

Forms

• Adverse Event Notification Form
  • Word fill-in form (83 KB)
  • PDF form (45 KB)
• Contextual Information Form
  • Word fill-in form (91 KB)
  • PDF form (39 KB)

Determine if an event is a reportable adverse event

• National Quality Forum Serious Reportable Adverse Events in Healthcare
• Department of Veterans Affairs National Center for Patient Safety Assessment Matrix
• Department of Veterans Affairs Nation Center for Patient Safety Triage Tool
• National Patient Safety Agency Incident Decision Tree

Root Cause Analysis

• Root cause analysis reporting formats
  • The Joint Commission on Accreditation of Health Care Organizations
  • The Dept. of Veterans Affairs National Center for Patient Safety
• Examples of root cause analysis aggregate review
  • Unintended retention of surgical sponge
  (153 KB PDF) 
  • Stage 3 or 4 pressure ulcer acquired after admission (137 KB PDF)

Washington State Resources (links)

• File a Complaint
• Patient Safety Quarterly newsletter
• Washington State Patient Safety Coalition
• Surgical Care and Outcomes Assessment Program (SCOAP)
• Washington State Hospital Association Patient (WSHA)
• Washington Ambulatory Surgery Center Association (WASCA)
• Puget Sound Health Alliance
• Foundation for Healthcare Quality
• Washington State Department of Health Licensing/Certification

Other Patient Safety Resources (links)

• The Joint Commission, Accreditation Program, Hospital: 2011 National Patient Safety Goals
• U.S. Dept. of Veterans Affairs, Ensuring Correct Surgery
• Institute for Clinical Systems Improvement (ICSI)
• U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality
• U.S. Dept. of Health & Human Services, Hospital Compare
• Centers for Medicare & Medicaid Services
• Institute for Healthcare Improvement
• Minnesota Department of Health, Patient Safety
• New Jersey Department of Health and Senior Services, Patient Safety Initiative
• Oregon Patient Safety Commission
• Pennsylvania Patient Safety Authority
• Canadian Patient Safety Institute

For Consumers

• National Quality Forum, Practices for Better Healthcare – 2010 Update
• Filing a complaint related to your Healthcare (Qualis Healthcare)
• File a Complaint
• Healthcare Advice from Dr. Carolyn Clancy

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