29 Events that Should Never Occur

January 25, 2015


The Minnesota Department of Health requires Minnesota hospitals to report 29 different adverse events that should never occur in hospitals. These reportable events are not an exclusive list of all acts of medical malpractice in the hospital, but are events that are patently the result of malpractice and require reporting. These events include:


Surgical Events:


1. Surgery on wrong body part


2. Surgery performed on wrong patient


3. Wrong surgery on the right patient


4. Leaving foreign object in patient after surgery


5. Death during or immediately after localized surgery that does not involve systemic disruption


Product or Device Events:


6. Patient death or serious injury due to use of contaminated drugs, devices or biologics


7. Patient death or serious injury from improper use of device


8. Patient death from intravascular air embolism except for cases involving certain neurosurgery procedures with inherent increased risk of air embolism


Patient Protection Events:


9. Discharging patient without decisionmaking capacity to wrong person


10. Patient death or serious injury due to disappearance of patient without decisionmaking capacity


11. Patient death or serious injury from suicide or suicide attempt in hospital, except for patients who die or have serious injury from self-inflicted injury prior to admission


Care Management Events:


12. Patient death or serious injury due to medication error


13. Patient death or serious injury due to unsafe administration of blood or blood products


14. Maternal death or serious injury after delivery in low risk pregnancy


15. Death or serious injury of neonate associated with labor and delivery during low risk pregnancy


16. Stage 3 or 4 ulcers that patients acquire after admission to facility, except for patients that had stage 2 ulcers documented at time of admission that progress to stage 3 ulcers


17. Artificial insemination with wrong donor sperm or wrong egg


18. Patient death or serious injury from fall while in facility


19. Irretrievable loss of biological specimen


20. Patient death or serious injury from failure to follow up or communicate laboratory, pathology, or radiology results


Environmental Events:


21. Patient death or serious injury from electric shock, except planned events including electric countershock


22. Delivery of wrong gas or a toxic substance to the patient in a gas line, such as an oxygen line


23. Patient death or serious injury from burn suffered in facility


24. Patient death or serious injury from use of or lack of restraints or bedrails


Potential Criminal Events:


25. Care by person impersonating a healthcare provider


26. Abduction of patient


27. Sexual assault of patient in facility or on grounds of facility


28. Death or serious injury of patient or staff member due to assault in or on facility grounds


Radiologic Events:


29. Death or serious injury to patient due to introduction of metallic object into the MRI area


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