Form HCQ-1 "Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility" - New Jersey

What Is Form HCQ-1?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HCQ-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form HCQ-1 "Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility" - New Jersey

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New Jersey Department of Health
NJDOH INTERNAL USE ONLY
REPORT OF SERIOUS PREVENTABLE
Report No.
ADVERSE EVENT
This form must be completed for any serious preventable adverse event. All information is protected based on the
provisions of the Patient Safety Act [N.J.S.A. 26:2H-12.25(f)]
Is this a revision of an earlier report to the Patient
If yes, give NJDOH Report
Facility Internal Tracking Number of
Safety Initiative for the same event?
Number:
this event, if known:
Yes
No
SECTION A - GENERAL INFORMATION
1. FACILITY IDENTIFICATION
Facility Name:
Facility License No.:
Facility Street Address:
County:
City:
State:
Zip Code:
Name of Person Submitting:
Telephone No.:
Title or Position:
Fax No.:
Email Address:
2. PLEASE SUPPLY A BRIEF DESCRIPTION (2 TO 3 SENTENCES) OF THE EVENT OR SITUATION YOU ARE REPORTING:
Event Information:
Event Date:
Time:
AM
PM
Date Event Discovered:
Time:
AM
PM
3. HOW WAS EVENT DISCOVERED? (Check only one)
1. Report by staff/physician
4. Assessment of patient/resident after event
2. Report by family/visitor
5. Review of chart/record
3. Report by patient/resident
6. Other:
4. PATIENT/RESIDENT INFORMATION
Inpatient
or
Outpatient
Admission through:
Emergency
Direct
Transfer from Acute
Transfer from LTC
Department
Admission
Care General Hospital
or Assisted Living
Patient/Resident Billing Number:
Patient/Resident Name:
Medical Record No.:
Street Address:
County:
City:
State:
Zip Code:
Date of Birth:
Gender:
Admission Date or Date of Ambulatory Encounter:
Admission Diagnosis:
Race:
Caucasian
Amer. Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Other:
Black
Asian
Unable to Determine
Ethnicity:
Non-Hispanic/Unable to Determine
Hispanic
HCQ-1
AUG 12
Page 1 of 3 Pages.
New Jersey Department of Health
NJDOH INTERNAL USE ONLY
REPORT OF SERIOUS PREVENTABLE
Report No.
ADVERSE EVENT
This form must be completed for any serious preventable adverse event. All information is protected based on the
provisions of the Patient Safety Act [N.J.S.A. 26:2H-12.25(f)]
Is this a revision of an earlier report to the Patient
If yes, give NJDOH Report
Facility Internal Tracking Number of
Safety Initiative for the same event?
Number:
this event, if known:
Yes
No
SECTION A - GENERAL INFORMATION
1. FACILITY IDENTIFICATION
Facility Name:
Facility License No.:
Facility Street Address:
County:
City:
State:
Zip Code:
Name of Person Submitting:
Telephone No.:
Title or Position:
Fax No.:
Email Address:
2. PLEASE SUPPLY A BRIEF DESCRIPTION (2 TO 3 SENTENCES) OF THE EVENT OR SITUATION YOU ARE REPORTING:
Event Information:
Event Date:
Time:
AM
PM
Date Event Discovered:
Time:
AM
PM
3. HOW WAS EVENT DISCOVERED? (Check only one)
1. Report by staff/physician
4. Assessment of patient/resident after event
2. Report by family/visitor
5. Review of chart/record
3. Report by patient/resident
6. Other:
4. PATIENT/RESIDENT INFORMATION
Inpatient
or
Outpatient
Admission through:
Emergency
Direct
Transfer from Acute
Transfer from LTC
Department
Admission
Care General Hospital
or Assisted Living
Patient/Resident Billing Number:
Patient/Resident Name:
Medical Record No.:
Street Address:
County:
City:
State:
Zip Code:
Date of Birth:
Gender:
Admission Date or Date of Ambulatory Encounter:
Admission Diagnosis:
Race:
Caucasian
Amer. Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Other:
Black
Asian
Unable to Determine
Ethnicity:
Non-Hispanic/Unable to Determine
Hispanic
HCQ-1
AUG 12
Page 1 of 3 Pages.
New Jersey Department of Health
NJDOH INTERNAL USE ONLY
REPORT OF SERIOUS PREVENTABLE
Report No.
ADVERSE EVENT
Continued
SECTION B - EVENT DETAILS
5. TYPES OF SERIOUS PREVENTABLE ADVERSE EVENTS (Check only one)
A. CARE MANAGEMENT EVENTS in a Health Care Facility
C. PRODUCT OR DEVICE EVENTS in a Health Care Facility
1. Patient/resident death/harm due to a medication error
1. Patient/resident
death/harm
due
to
the
use
of
contaminated drugs/devices/biologics
2. Patient/resident death/harm due to a hemolytic reaction
due to the administration of ABO-incompatible blood or
2. Patient/resident death/harm due to the use/function of a
blood products
device in patient/resident care in which the device is
used/functions other than as intended
3. Maternal death/harm due to labor/delivery in a low-risk
pregnancy
3. Patient/resident death/harm due to intravascular air
embolism
4. Patient/resident death/harm due to hypoglycemia
4. Patient/resident death/harm due to the use of a
5. Patient/resident death/harm due to failure to identify and
single-use device in which the device is used/functions
treat hyperbilirubinemia in neonates
other than as intended:
6. Stage 3 or 4 pressure ulcers acquired after admission
new single-use device
(excludes progression from Stage II to Stage III if
Stage II
was
recognized
and
documented
upon
reprocessed single-use device
admission)
5. Other event causing patient/resident death or harm that
7. Patient/resident death/harm due to spinal manipulative
lasts seven days or is present at discharge
therapy
8. Other event causing patient/resident death or harm that
lasts seven days or is present at discharge
D. SURGERY-RELATED EVENTS
1. Surgery performed on the wrong body part
2. Surgery performed on the wrong patient
B. ENVIRONMENTAL EVENTS in a Health Care Facility
3. Wrong surgical procedure performed on a patient
1. Patient/resident death/harm due to an electric shock
4. Retention of a foreign object in a patient after surgery or
2. Any event in which a line designated for oxygen/other
other procedure
gas to be delivered to a patient/resident contains the
5. Intraoperative or post-operative (i.e., within 24 hours)
wrong gas or is contaminated by toxic substances
coma, death or other serious preventable adverse event
3. Patient/resident death/harm due to a burn incurred from
for an ASA Class I inpatient or for any ASA Class same
any source
day surgery patient or outpatient (includes situations
4. Patient/resident death/harm due to a fall
where anesthesia was administered)
5. Patient/resident death/harm due to the use of restraints
6. Other event causing patient death or harm that lasts
or bedrails
seven days or is present at discharge
6. Other event causing patient/resident death or harm that
lasts seven days or is present at discharge
E. PATIENT/RESIDENT PROTECTION EVENTS in a Health
Care Facility
1. Infant discharged to the wrong person
2. Patient/resident death/harm due to patient elopement
3. Patient/resident suicide/attempted suicide
4. Other event causing patient/resident death or harm that
lasts seven days or is present at discharge
HCQ-1
AUG 12
Page 2 of 3 Pages.
New Jersey Department of Health
NJDOH INTERNAL USE ONLY
REPORT OF SERIOUS PREVENTABLE
Report No.
ADVERSE EVENT
Continued
6. IF 5.A.1 WAS SELECTED, COMPLETE THIS SECTION:
What type of medication error occurred? (Check all that apply)
Administration After Order Discontinued/Expired
Wrong Drug
Monitoring Error
Wrong Frequency
Omission
Wrong Patient
Wrong Diluent/Concentration/Dosage Form
Wrong Route
Wrong Dose
Wrong Time
Other:
Brand/Product Name (If Applicable):
Generic Name:
7. WHERE WAS THE PATIENT/RESIDENT WHEN THE EVENT OCCURRED?
(Check all that apply)
Patient Room (Check Unit below)
Cardiac Catheterization Laboratory
Emergency Department
Patient Bathroom (Check Unit below)
Emergency Department Crisis Screening/Observation
Hallway/Common Area
Units
In Transit
Med/Surg
Laboratory
ICU/CCU/TCU
NICU
Step Down
Nursery
Telemetry
Operating Room
Labor/Delivery
PACU
Procedure Room
Behavioral Health
Radiology
Rehabilitation Areas
Other:
8A. IMMEDIATE CLINICAL ACTION(S) TAKEN FOR THE PATIENT:
8B. IMMEDIATE CORRECTIVE ACTIONS TO PREVENT FUTURE SIMILAR EVENTS:
HCQ-1
AUG 12
Page 3 of 3 Pages.
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