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    Infectious Disease Control Unit
    Mail Code: 1960
    PO BOX 149347 - Austin, TX 78714-9347
    1100 West 49th Street, Suite T801
    Austin, TX 78714

    Phone: 512 776 7676
    Fax: (512) 776-7616


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PAE Reporting

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New Reporting Required for Hospital and Ambulatory Surgical Centers

Mandatory reporting of Preventable Adverse Events occurring at Texas health care facilities, including hospitals and ambulatory surgery centers, will begin January 1, 2015.  This comes following amendments to the Texas Health and Safety Code during the 81st Legislative Session that require both reporting by healthcare facilities to the Department of State Health Services and that the Department shall post PAE data on its public website.

Preventable Adverse Events that are required to be reported are:

  • Health care-associated adverse conditions or events for which the Medicare program will not provide additional payment to the facility under a policy adopted by the federal Centers for Medicare and Medicaid Services;  and
  • Events included in the list of adverse events identified by the National Quality Forum. 

The executive commissioner may exclude an adverse event from the reporting requirement if the executive commissioner, in consultation with the advisory panel, determines that the adverse event is not an appropriate indicator of a preventable adverse event.Initial educational sessions will be provided across Texas and by webinar during April – July.  Any group that is interested will be considered for a face to face presentation upon request. Go to Education and Training for reporting training.

Vickie Gillespie, RN, BSN, Clinical Analyst

Preventable Adverse Events

Healthcare Safety Group

Emerging and Acute Infectious Disease Branch

PAE questionsAsk us your PAE Questions!

 

TEXAS PREVENTABLE ADVERSE EVENT REPORTING

First Tier PAE Reporting Beginning January 1st, 2015:

SURGICAL OR INVASIVE PROCEDURE EVENTS

  1. Surgeries or invasive procedures involving a surgery on the wrong site, wrong patient, wrong procedure.
  2. Foreign object retained after surgery.
  3. Post-operative death of an ASA Class 1 Patient.

PATIENT PROTECTION EVENTS

  1. Discharge or release of a patient of any age, who is unable to make decisions, to someone other than an authorized person.

CARE MANAGEMENT EVENTS

  1. Death or severe harm associated with a fall in a health care facility resulting in a fracture, dislocation, intracranial injury, crushing injury, burn or other injury.
  2. Patient death or severe harm associated with unsafe administration of blood or blood products.
  3. Perinatal death or severe harm (maternal or neonate) associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility.
  4. Patient death or severe harm from the irretrievable loss of an irreplaceable biological specimen.
  5. Patient death or severe harm due to failure to follow up or communicate laboratory, pathology or radiology test results.

ENVIRONMENTAL EVENTS

  1. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, wrong gas, or are contaminated by toxic substances.
  2. Patient death or severe harm associated with use of physical restraints or bedrails while being cared for in a health care facility.

POTENTIAL CRIMINAL EVENTS

  1. Abduction of a patient of any age.
  2. Sexual abuse or assault of a patient within or on the grounds of a health care facility.
  3. Death or severe harm of a patient resulting from a physical assault that occurs within or on the grounds of a health care facility.

Second Tier PAE Reporting Beginning January 1st, 2016:

SURGICAL OR INVASIVE PROCEDURE EVENTS

  1. Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) after total knee replacement or after hip replacement.
  2. Iatrogenic Pneumothorax with venous catheterization.

PATIENT PROTECTION EVENTS

  1. Patient death or severe harm associated with patient elopement.
  2. Patient suicide, attempted suicide or self-harm resulting in severe harm, while being cared for in a health care facility.

CARE MANAGEMENT EVENTS

  1. Stage III, Stage IV or Unstageable pressure ulcer acquired after admission/presentation to a health care facility.

ENVIRONMENTAL EVENTS

  1. Patient death or severe harm associated with an electric shock while being cared for in a health care facility.
  2. Patient death or severe harm associated with a burn incurred from any source while being cared for in a health care facility.

RADIOLOGIC EVENT

  1. Patient death or severe harm associated with the introduction of a metallic object into the MRI area.

POTENTIAL CRIMINAL EVENTS

  1. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider.

Third Tier PAE Reporting Beginning January 1st, 2017:

SURGICAL OR INVASIVE PROCEDURE EVENTS

  1. Surgical site infections following a spinal procedure, shoulder procedure, elbow procedure, laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery or cardiac implantable electronic device.
  2. Patient death or severe harm associated with intravascular air embolism that occurs while being cared for in a health care facility.

PRODUCT OR DEVICE EVENTS

  1. Patient death or severe harm resulting from contaminated drugs/devices or biologics provided by the health care facility.
  2. Patient death or severe harm associated with the use or function of a device in patient care, in which the device is used or functions other than as intended.

CARE MANAGEMENT EVENTS

  1.  Patient death or severe harm associated with a medication error.
  2.  Artificial insemination with the wrong donor sperm or wrong egg.
  3.  Poor glycemic control: hypoglycemic coma.
  4.  Poor glycemic control: diabetic ketoacidosis.
  5.  Poor glycemic control: nonketotic hyperosmolar coma.
  6. Poor glycemic control: secondary diabetes with ketoacidosis.
  7. Poor glycemic control: secondary diabetes with hyperosmolarity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

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Last updated September 03, 2015