The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	
Circular Letter: DHCQ 07-12-478 

TO: 		Hospital Chief Executive Officers 
Risk Managers 

FROM: 	Paul Dreyer, Ph.D. 
                      Bureau Director

DATE: 	December 13, 2007 

SUBJECT: 	Hospital Reporting of Serious Incidents
 
This letter is one of an ongoing series of communications with hospitals regarding the obligation to report serious incidents to the Department as set out in hospital licensure regulations at 105 CMR 130.331.  Previous circular letters on reporting may be accessed via the Department’s website at http://www.mass.gov/dph/dhcq under the “Health Care Quality Topics” heading and “Circular Letters”.

This letter, which has been developed following consultation with the Board of Registration in Medicine and the Massachusetts Hospital Association, announces a change in the reporting process and will serve to distribute the Department’s revised fax reporting form (attached).  The fax reporting form as revised will allow both hospitals and the Department to easily identify those facility reported incidents which meet the National Quality Forum’s (NQF) definition of a “serious reportable incident”.

In order to promote consistency in reporting, the Department is asking hospitals to use the NQF list in its most current format when identifying serious reportable events (see http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf. for the most current listing of serious reportable events as of the date of this circular letter).  This step is responsive to the recommendations of the Accountability Project in which the Department, MA Coalition for the Prevention of Medical Errors, MA Hospital Association and many other stakeholders participated.  We all believe that using a standardized set of definitions will allow us to better track and trend such events in order to get to the important work of learning and improvement.

It is important to note that this revision to the reporting process does not in any way change the types of events that hospitals have been required to report to the Department.  Instead, our fax reporting form will now contain an additional field for hospitals to use to self-report whether or not the report concerns a serious reportable incident as defined by the NQF.

Please contact Lillian Jette at the Division of Health Care Quality at (617) 753-8204 if you have any questions on this reporting requirement. 

Attachment:  Hospital Fax Reporting Form 12-2007

HOSPITAL FAX REPORTING
OF INCIDENTS AND ABUSE

GENERAL INSTRUCTIONS:

1.	These instructions apply to reporting all hospital incidents, and suspected abuse, neglect, mistreatment and misappropriation of patient property under the Patient Abuse Law.                                                

2.	Complete a separate blank form for each occurrence following the instructions below.

3.	Use the attached tables to enter a description for those items that are marked “see table.”

4.	Submit your completed report by fax to the Department immediately for (1) fires; (2) suicide; (3) serious criminal acts; (4) pending or actual strike; (5) serious physical injury or harm to a patient resulting from accident or unknown cause; and, (6) suspected abuse, neglect, mistreatment or misappropriation involving nursing home, rest home, home health, homemaker and hospice patients.  Notify the Department immediately by phone at 617-753-8150 of any deaths resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation of the facility for any reason.  Submit other completed reports within seven days of the date of the occurrence of an incident seriously affecting the health and safety of patients.

5.	Fax your completed report to the Department at 617-753-8165.

LINE BY LINE INSTRUCTIONS

PAGE 1 OF REPORT FORM:

FROM:  Please provide the name and address of the facility making the report.  

DATE OF REPORT:  Enter the date that you are submitting your report to the Department.

FOR ABUSE, NEGLECT, MISTREATMENT or MISAPPROPRIATION OCCURING IN NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE SETTING, NOT AT THE REPORTING HOSPITAL:

FACILITY/AGENCY NAME: Indicate the name of the provider at which the suspected
abuse, neglect, mistreatment or misappropriation occurred.

ADDRESS:  Indicate the address (city or town, if street address is not known) of the
provider at which the suspected abuse, neglect or misappropriation occurred.

GENERAL INFORMATION:  Please indicate your name and title, as the person preparing this report, a phone number at which we can contact you if we need additional information, 	
	and the date and time of the occurrence.  If you are not able to determine when the event occurred, state “unknown”.

Instructions - Page 1
LINE BY LINE INSTRUCTIONS - CONTINUED 

PATIENT INFORMATION:  Please provide information here regarding the patient involved.  The information reported here should reflect the patient’s condition prior to the occurrence.  If more than one patient was injured, or if one patient has injured another patient, provide additional patient information under the narrative portion of the report or on an additional page.  Please indicate:

NAME:  The patient’s first and last name.  

AGE; SEX; ADMISSION DATE:  Enter each for the named patient.

AMBULATORY STATUS:  Select the term from Table #1, “Ambulatory Status”, that most closely describes the patient’s ability to walk.

ADL STATUS:  Activities of Daily Living (ADLs) such as eating, dressing or personal grooming. Select the term from Table #2, “Patient ADL Status”, that most closely describes the patient’s ability to perform these functions.

COGNITIVE LEVEL:  Select the term from Table #3, “Patient Cognitive Status”, that  best describes the patient’s cognitive status at the time of the occurrence.

MENTALLY RETARDED/DEVELOPMENTALLY DISABLED:  Indicate whether or not the
patient is mentally retarded or developmentally disabled.  If the resident is either, indicate the name of the Service Coordinator (mentally retarded) or Case Manager (developmentally disabled) assigned to the patient, if known.

REPORT DETAIL:

SERIOUS REPORTABLE EVENT:  Indicate whether or not this is a report of a “serious reportable event” as described in the current National Quality Forum (NQF) list of serious reportable events, and if so, enter the text description of event from the NQF list at: http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf 

DPH OCCURRENCE TYPE:  For all reports, select the term from Table #4, “Occurrence Type”, that best describes the occurrence you are reporting.  You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

TYPE OF HARM:  Select the term from Table #5, “Type of Harm”, that best describes the harm or injury that resulted from the occurrence. You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report. Note that harm includes psychological injury as well as physical harm, and SHOULD NOT BE DESCRIBED AS “NONE” SIMPLY BECAUSE THERE WAS NO PHYSICAL HARM.

BODY PART AFFECTED:  Use terms such as “arm”, “foot”, etc.; indicate left or right when it applies.

Instructions - Page 2

LINE BY LINE INSTRUCTIONS - CONTINUED

PATIENT’S ACTIVITY AT TIME OF OCCURRENCE:  Select the term from Table #6, “Patient’s Activity”, that best describes the patient’s activity at the time of the  occurrence.  You may select “Other” and describe what happened in one or two words if none of the examples listed are applicable to your report.

PLACE OF OCCURRENCE:  Specify where the event occurred.  Examples would include: “patient’s room”, “dining room”, “shower room”, or any other short phrase that specifies the type of setting in which the occurrence took place.

WHAT EQUIPMENT, IF ANY, WAS BEING USED AT TIME OF OCCURRENCE:  Specify if any equipment was in use, such as “Hoyer lift”, or “walker”.

ANY SAFETY PRECAUTIONS IN PLACE:  Check the “yes” or “no”.  If “yes”, describe the precautions that were in place. 

PAGE 2 OF REPORT FORM:

NARRATIVE:  Describe fully what occurred.  Indicate who, what, when, where, why and how what is being reported occurred.  Include information on how any person injured was treated.  If there were any unusual circumstances involved, describe these fully.

CORRECTIVE MEASURES NARRATIVE:  Describe what actions have been taken in response to the occurrence.  

NOTIFICATION:  Indicate whether or not the patient’s family and physician, and police were notified.  Provide the name of the physician notified.  

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:  Indicate who was present and in charge at the facility (not on the unit) when the occurrence reported happened.  

WITNESS INFORMATION:  List the name and title for individuals who saw or heard what occurred.  Indicate if any of witnesses were directly involved in what occurred.  Other patients, visitors and volunteers should be listed as witnesses if they have direct knowledge of what occurred.

ACCUSED INFORMATION:  When reporting suspected abuse, neglect or misappropriation, indicate the name of the accused, a phone number at which the accused can be contacted, if the accused is a nurse, nurse aide or other licensed professional please indicate the individual’s license or registration number.  Check the appropriate block if you are not reporting abuse, or the identity of the person(s) suspected of abuse, neglect or misappropriation of a patient’s money or belongings is unknown.  If more than one 
	individual is suspected, indicate on an additional sheet the other individual’s names, a phone number at which they may be contacted, and if any person was acting as a nurse aide, home health aide or homemaker.

Instructions - Page 3

	REPORTING TABLES:

Table #1:  Ambulatory Status:				Table #2:  Patient ADL Status:

Independent							Independent
Supervised							Supervised
Dependent/Assist						Dependent
Wheels Self							Unknown
Wheelchair							Other
Bedfast
Unknown

Table #3:  Patient’s Cognitive Status:			Table #4:  Occurrence Type:

Alert/Oriented							Fall 
Dementia							Abuse
Confused							Neglect 
Alzheimer’s							Misappropriation
Comatose							Surgical Error
Unknown							Medication Error
Other								Accident
								Emergency Services
Table #5: Type of Harm:					Death
								Suicide
Fracture							Infection Control
Laceration							Criminal Act
Bruise/Hematoma						Fire
Reddened Area						Pending Strike
Dislocation							Equipment Malfunction
Burn								Injury of Unknown Origin
Unwelcome Sexual Contact/Advance			Other (Describe)
Emotional Harm/Upset
Care Not Provided						Table #6:  Patient’s Activity 
Quality of Care
Decline in Condition						Ambulating
Infection							Toileting
Confinement							Transfer/Assist
Property							Getting Out of Bed
Funds								Getting Up From Chair
Death								Reaching
No Harm							Standing/Sitting Still
Other (Describe)						Crowded Area
Unknown							Other(Describe)
								Unknown

Instructions - Page 4
HOSPITAL FAX REPORT FORM

TO:	 INTAKE STAFF 
	 DEPARTMENT OF PUBLIC HEALTH, DIVISION OF HEALTH CARE QUALITY
	 FAX NUMBER: 617-753-8165

FROM:  Hospital Name:	__________________________________________
	  Address (Street):	__________________________________________
	  Address (City/Town)	__________________________________________

DATE OF REPORT:	  	_______________	NUMBER OF PAGES:  ____________

IF ABUSE, NEGLECT, or MISAPPROPRIATION OCCURING IN NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE, NOT THE REPORTING HOSPITAL:
ABOUT: Facility/Agency Name:__________________________________________
	  Address:                   	___________________________________________

GENERAL INFORMATION:
Report prepared by:		___________________________________________
Title:				___________________________________________
Phone Number:		(________)__________-___________Ext:_________
Date of Occurrence:		Month____________ Date_________ Year________
Time of Occurrence:		________________________ am______ pm_______

PATIENT INFORMATION:
Name:				First ________________ Last__________________
Age:				______________
Sex:				Male _________   Female __________
Admission Date:		Month___________ Date__________ Year________
Ambulatory Status (See table #1):________________________________________
ADL Status (See table #2):	___________________________________________
Cognitive Level (See table #3):___________________________________________
Mentally Retarded/Developmentally Disabled: ____ Yes ____No.  
 If yes, Service Coordinator or Case Manager (if known): _____________________________ 

REPORT DETAIL:

Is this a serious reportable incident as defined by NQF ____ Yes ____No.  
 If yes, type (see http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf): 
 ____________________________________________________________________________

DPH Occurrence Type (See table #4):___________________________________
Type of Harm (See table #5):__________________________________________
Body Part Affected:		__________________________ L:_____  R: _____
Patient’s activity at  time of
 occurrence (See table #6):	__________________________________________
Place of Occurrence:		__________________________________________
What equipment, if any, was being
 used at time of occurrence?	__________________________________________
Any safety precautions in place? Yes________  No_________
 If yes, describe what preventive measures were in place:  

[Page 1 of 2.]
REPORTING HOSPITAL: __________________  DATE OF OCCURRENCE: _________

NARRATIVE: (Please address the following: What happened?  What factors contributed to the occurrence?  Any relevant information which establishes cause?  Have there been similar incidents in the past?  How  were the injuries treated?  [Attach additional pages as needed.] )

  

	
Were there any unusual circumstances involved? Yes________ No__________ If yes, please describe.  [Attach additional pages as needed.]

CORRECTIVE MEASURES NARRATIVE: N/A - Incident occurred with another provider _______. (Please address the following:  Was there an internal investigation: Yes_____ No_____ If No - why?  If yes-  What are the investigation findings?   What action was taken with regard to: Patient?; Staff?; Facility practice?  What is the patient's current status?  What corrective action taken regarding equipment involved, if applicable?  [Attach additional pages as needed.] )

NOTIFICATION:
Was family notified:		Yes__________  No_____________
Was MD notified:		Yes__________  No_____________
Name of MD if notified:  	_________________________________________ 
Were  police notified: 		Yes__________  No_____________

STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:
N/A (Incident occurred with another provider):_______
Name:					Title:			Directly Involved:
_____________________________________________________YES_____NO_______

WITNESS INFORMATION:	        (Check here if unwitnessed: ____________)
Name:					Title:		          Directly Involved:
_____________________________________________________YES_____NO_______
_____________________________________________________YES_____NO_______

ACCUSED INFORMATION:  (Check here if unknown or not applicable: _________)
Name:					Telephone #:			
________________________________(_____)_____-_______  AIDE ___; RN/LPN ____
If RN/LPN or other licensed individual, indicate license #:______________________

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