Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 200 - REPORTING OF HEALTH CARE-ASSOCIATED INFECTIONS AND PREVENTABLE ADVERSE EVENTS
Subchapter A - CONTROL OF COMMUNICABLE DISEASES
Section 200.7 - Schedule for HAI and PAE Reporting
Universal Citation: 25 TX Admin Code ยง 200.7
Current through Reg. 49, No. 38; September 20, 2024
(a) Facilities shall submit HAI and designated PAE data according to the following schedule in Table 1.
(1) HAI and
designated PAE data for device days and procedures occurring between January 1
and March 31 shall be submitted no later than May 31 of the same calendar
year.
(2) HAI and designated PAE
data for device days and procedures occurring between April 1 and June 30 shall
be submitted no later than August 31, of the same calendar year.
(3) HAI and designated PAE data for device
days and procedures occurring between July 1 and September 30 shall be
submitted no later than November 30 of the same calendar year.
(4) HAI and designated PAE data for device
days and procedures occurring between October 1 and December 31 shall be
submitted no later than February 28 of the following calendar year.
(b) If any of the dates in subsection (a) of this section fall on a weekend or holiday, facilities shall submit on the following business day.
(c) Reporting of deaths shall follow the same reporting time line as HAI and PAE reporting in this section.
(d) Health care facilities shall begin reporting TxHSN-reported PAEs data as outlined starting on January 1, 2015.
(1) Facilities will report the following PAEs
effective January 1, 2015.
(A) Surgeries or
invasive procedures involving a surgery on the wrong site, wrong patient, wrong
procedure or a foreign object retained after surgery.
(B) Patient death or severe harm associated
with unsafe administration of blood or blood products.
(C) Patient 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.
(D) Post-operative death of an ASA Class 1
Patient.
(E) Discharge or release
of a patient of any age, who is unable to make decisions, to someone other than
an authorized person.
(F) Perinatal
death or severe harm (maternal or neonatal) associated with labor or deliver in
a low-risk pregnancy while being cared for in a health care facility.
(G) Patient death or severe harm resulting
from failure to follow up or communicate laboratory, pathology or radiology
test results.
(H) 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.
(I) Patient death or severe harm associated
with use of physical restraints or bedrails while being cared for in a health
care facility.
(J) Abduction of a
patient of any age.
(K) Sexual
abuse or assault of a patient within or on the grounds of a health care
facility.
(L) Patient death or
severe harm of a patient resulting from a physical assault that occurs within
or on the grounds of a health care facility.
(M) Patient death or severe harm resulting
from the irretrievable loss of an irreplaceable biological specimen.
(2) Facilities will report the
following PAEs effective January 1, 2016.
(A)
Stage III, Stage IV or Unstageable pressure ulcer acquired after
admission/presentation to a health care facility.
(B) Patient death or severe harm associated
with patient elopement.
(C) Patient
suicide, attempted suicide or self-harm that results in severe harm, while
being cared for in a health care facility.
(D) Any instance of care ordered by or
provided by someone impersonating a physician, nurse, pharmacist or other
licensed health care provider.
(E)
Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) after total knee
replacement or after hip replacement.
(F) Patient death or severe harm associated
with an electric shock while being cared for in a health care
facility.
(G) Patient death or
severe harm associated with a burn incurred from any source while being cared
for in a health care facility.
(H)
Iatrogenic Pneumothorax with venous catheterization.
(I) Patient death or severe harm associated
with the introduction of a metallic object into the MRI area.
(3) Facilities will report the
following PAEs effective January 1, 2017.
(A)
Patient death or severe harm associated with intravascular air embolism that
occurs while being cared for in a health care facility.
(B) Poor glycemic control: diabetic
ketoacidosis.
(C) Poor glycemic
controls: nonketonic hyperosmolar coma.
(D) Poor glycemic control: hypoglycemic
coma.
(E) Poor glycemic control:
secondary diabetes with ketoacidosis.
(F) Poor glycemic control: secondary diabetes
with hyperosmolarity.
(G)
Artificial insemination with the wrong donor sperm or wrong egg.
(H) Patient death or severe harm associated
with the use of contaminated drugs/devices or biologics provided by the health
care facility.
(I) 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.
(J) Patient death or severe harm associated
with a medication error.
(K)
Surgical site infections following a spinal procedure, shoulder procedure,
elbow procedure, laparoscopic gastric bypass, gastroenterostomy, laparoscopic
gastric restrictive surgery or cardiac implantable electronic device.
(4) Amendments to this list of
PAEs may be adopted at the discretion of the executive commissioner as
recommended by CMS and NQF.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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