Wash. Rev. Code § 70.56.020

Notification of Adverse Health Events

When a medical facility confirms that an adverse event has occurred, it must submit to the Department of Health notification of the event, with the date, type of adverse event, and any additional contextual information included, within 48 hours.  Additionally, a report must be made and filed with the department within 45 days.  The facility has 60 days following submission of the report to make any necessary revisions or amendments.  The report must identify the facility, but may not include any identifying information for any of the health care professionals, facility employees, or patients involved.  As part of the report, the facility must conduct a root cause analysis of the event, described the corrective action plan that will be implemented, or provide an explanation of any reasons for not taking corrective action.

The following events shall be considered “adverse” for the purpose of reporting:

Surgical Events

• Surgery performed on the wrong body part

• Surgery performed on the wrong patient

• Wrong surgical procedure performed on a patient

• Unintended retention of a foreign object in a patient after surgery or other procedure

• Intraoperative or immediately postoperative death in an ASA Class I patient

Product of Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility

• 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

• 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 leaving the facility without

permission

• 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 (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 disability associated with a hemolytic reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products

• Maternal death or serious disability associated with labor or delivery in 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 associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns

• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

• Patient death or serious disability due to spinal manipulative therapy

• Artificial insemination with the wrong donor sperm or wrong egg

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 substances

• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility

• Patient death or serious disability 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 assault on a patient within or on the grounds of a healthcare facility

• Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

Related Laws: Wash. rev. code § 70.56.040; Wash. rev. code § 70.56.050