Legislation and Guidelines
This document outlines final guidance to acute healthcare facilities in this Commonwealth in making determinations about whether specific occurrences meet the statutory definitions of serious events, incidents and infrastructure failures as defined in section 302 of the Medical Care Availability and Reduction of Error (MCARE) Act (MCARE Act) (40 P. S. § 1303.302).
Reporting Decision Tree
Unsure of how to report a Serious Event or Incident? Follow the Reporting Decision Tree for step by step instructions.
Event Reporting Examples
Transfers from ASF
Narrative: Patient presented to reproductive ASF for egg retrieval in 10/10 pain. Discussed differential diagnosis and treatment options. Decided to proceed with egg retrieval to see if that would relieve pain. It did not. Patient was sent to hospital to have procedure done to rule out ovarian torsion.
Dietary Order Error
Narrative: Patient with a recent CVA was ordered a pureed diet with thickened liquids. Three days later, the diet order was revised to a pureed diet with thin liquids, but the recommendation for thickened liquids remained in the order comments. Due to the inconsistency between the order and the comments, dietary staff held the meal tray until the order could be clarified. The patient did not receive a meal tray for 4 days. Patient developed acute kidney injury, likely from poor oral intake. Kidney injury resolved after oral intake was resumed.
Narrative: Mother presented to her physician office for a labor check with high-risk pregnancy and complaints of diaphoresis, dizziness, and vomiting. Fetal heart tones were unable to be obtained and the patient was sent to the hospital. During initial assessment at the hospital fetal heart tones were still unable to be obtained. Ultrasound confirmed fetal demise. Sudden gush of blood noted, and diagnosis of placental abruption made. Baby was delivered stillborn via Cesarean section.
Return to the Operating Room
Narrative: A patient returns to the operating room for a uterine repair 2 days post c-section.
Wrong Site Procedure(1)
Narrative: Intravitreal medication was injected into the incorrect eye. Intravitreal medication was then injected into the correct eye.
Retained Foreign Object: Example 1
Narrative: The final sponge count indicated a missing sponge. The patient was still in the operating room, but the incision was already closed. The surgeon reopened the incision and retrieved the sponge.
Retained Foreigh Object: Example 2
Narrative: A drill bit broke during orthopedic surgery, and the tip became lodged in the patient’s femur. The surgeon made the decision to leave the drill tip in place because risks associated with removal outweighed the benefits of removal.
Intentionally Retained Sponges - Example 3
Narrative: Following cardiac surgery, surgeon packed patient’s chest with four lap sponges and intentionally left them in place with chest open. During patient’s planned return to the OR, the sponges will be removed prior to closing the chest.
Nasogastric Tube Misplacement Example 1
Narrative: Patient dislodged nasogastric tube several times, resulting in multiple reinsertions. Chest X-ray after last reinsertion revealed bilateral pneumothoraces. Bilateral chest tubes placed.
Nasogastric Tube Misplacement Example 2
Narrative: The patient status post nasogastric tube insertion. Chest X-ray revealed a misplacement into the left lung with a small pneumothorax. Patient did not require a chest tube. Patient will continue to be monitored for respiratory distress.