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 827 - FREESTANDING MEGAVOLTAGE RADIATION THERAPY FACILITY
Section He-P 827.15 - Adverse Event Reporting

Universal Citation: NH Admin Rules He-P 827.15

Current through Register No. 40, October 3, 2024

(a) Pursuant to RSA 151:37, the FMRTF administrator or designee, as a part of the parent hospital, 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, available as noted in Appendix A.

(2) Any misadministration as defined in He-P 4047.03(f) ; and

(3) The exposure of a patient to a non-aerosolized blood borne pathogen by a health care worker's intentional, unsafe act. An act by FMRTF staff resulting in an infection or disease shall be considered to be purposefully unsafe if it meets the following criteria:

a. There was an intentional act or reckless behavior;

b. No reasonable person with similar qualifications, training, and experience would have acted the same way under similar circumstances; and

c. There were no extenuating circumstances that could justify the act.

(b) 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 working 15 days after discovery of event, including:

(1) Provider information;

(2) Patient information;

(3) Event information; and

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

(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 FMRTF determines that one is not required.

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

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

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

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

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

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

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