TxHSN PAE Reporting Schedule

Texas Preventable Adverse Event Reporting 

3 Tier Phase-In Implementation

First Tier PAE Reporting Beginning 

January 1, 2015

1. Surgeries or invasive procedures involving a surgery on the wrong site, wrong patient, wrong procedure.
2. Foreign object retained after surgery.
3. Vascular Catheter-Associated Infection.
4. Post-operative death of an ASA Class 1 Patient.
5. Discharge or release of a patient of any age, who is unable to make decisions, to someone other than an authorized person.
6. 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.
7. Abduction of a patient of any age.
8. Sexual abuse or assault of a patient within or on the grounds of a health care facility.
9. Patient death or severe harm resulting from a physical assault that occurs within or on the grounds of a health care facility.
10. Patient death or severe harm due to a fall in a health care facility resulting in a fracture, dislocation, intracranial injury, crushing injury, burn or other injury.
11. Patient death or severe harm associated with unsafe administration of blood or blood products.
12. Patient death or severe harm from the irretrievable loss of an irreplaceable biological specimen.
13. Patient death or severe harm due to failure to follow up or communicate laboratory, pathology or radiology test results.
14. Patient death or severe harm associated with use of physical restraints or bedrails while being cared for in a health care facility.
15. 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.

Second Tier PAE Reporting Beginning

January 1, 2016

1. Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) after total knee replacement or after hip replacement.
2. Iatrogenic Pneumothorax with venous catheterization.
3. Stage III, Stage IV or Unstageable pressure ulcer acquired after admission/presentation to a health care facility.
4. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider.
5. Patient suicide, attempted suicide or self-harm resulting in severe harm, while being cared for in a health care facility.
6. Patient death or severe harm associated with patient elopement.
7. Patient death or severe harm associated with an electric shock while being cared for in a health care facility.
8. Patient death or severe harm associated with a burn incurred from any source while being cared for in a health care facility.
9. Patient death or severe harm associated with the introduction of a metallic object into the MRI area.

Third Tier PAE Reporting Beginning

January 1, 2017

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. Artificial insemination with the wrong donor sperm or wrong egg.
3. Poor glycemic control resulting in hypoglycemic coma.
4. Poor glycemic control resulting in diabetic ketoacidosis.
5. Poor glycemic control resulting in nonketonic hyperosmolar coma.
6. Poor glycemic control resulting in secondary diabetes with ketoacidosis.
7. Poor glycemic control resulting in secondary diabetes with hyperosmolarity.
8. Patient death or severe harm resulting from contaminated drugs/devices or biologics provided by the health care facility.
9. 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.
10. Patient death or severe harm associated with intravascular air embolism that occurs while being cared for in a health care facility.
11. Patient death or severe harm associated with a medication error.