New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 802 - RULES FOR HOSPITALS
Section He-P 802.15 - Adverse Event Reporting

Universal Citation: NH Admin Rules He-P 802.15

Current through Register No. 40, October 3, 2024

(a) Pursuant to RSA 151:38, the administrator or designee shall report to the department the following adverse events:

(1) Serious reportable events and specifications published in the National Quality Forum's "Serious Reportable Events in Healthcare- 2011 Update" http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id & ItemID;=69573, as available as noted in Appendix A; and

(2) The exposure of a patient to a non-aerosolized blood borne pathogen by a health care worker's intentional unsafe act.

(b) An act by hospital or ambulatory surgery center staff resulting in an infection or disease shall be considered to be purposefully unsafe if it meets the following criteria:

(1) There was an intentional act or reckless behavior;

(2) No reasonable person with similar qualifications, training, and experience would have acted the same way under similar circumstances; and

(3) There were no extenuating circumstances that could justify the act.

(c) If the licensee suspects an adverse event occurred, the administrator or designee shall send a report to the department in electronic or paper format, within 15working days after discovery of the event, including:

(1) Licensee information;

(2) Patient information;

(3) Event information; and

(4) Type of occurrence as listed in (a) above.

(d) For events reported in (a) above, the licensee shall, within 60 days after discovery of the event, provide the department:

(1) An analysis that includes the type of harm and contributing factors; and

(2) A corrective action plan that includes what corrective actions are planned, who is responsible for implementation, when the action will be implemented and what measurements will be used to evaluate the corrective action plan or the justification for not implementing a corrective action plan if the licensee determines that one is not required.

(e) If the licensee suspects that it received a patient from a sending hospital that was subject to an adverse event, then the receiving administrator or designee shall notify the sending hospital's administrator or designee and the department. The department shall inform the sending hospital that a report is required in accordance with (a) above.

(f) Upon receipt of a report of an adverse event, the department shall:

(1) Acknowledge receipt of the event and review the information for completeness;

(2) Review the corrective action plan for system changes that reduce the risk repeat of similar adverse events;

(3) Communicate specific concerns to the licensee if the department does not find the corrective action plan credible;

(4) Track and analyze adverse events for trends and underlying system problems; and

(5) Provide information and make referrals to other state agencies as appropriate.

#5846, eff 6-22-94, EXPIRED: 6-22-00

New. #9580, eff 10-24-09

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