1. (1) "Adverse event" means an injury associated with healthcare processes rather than the underlying patient condition or disease itself and that prolongs medical intervention or results in harm, disability, or death.
2. (2) "Causal analysis" means a process for identifying the basic or causal factor or factors that underlie variation in performance, resulting in the occurrence or possible occurrence of a patient safety event, which may include a root cause analysis, a failure mode and effect analysis, hazards analysis, evidence review, observation or any other relevant analytical process aimed at identifying and understanding contributing factors.
3. (3) "Contaminated" means contamination that can be seen with the naked eye, or with use of detection mechanisms in general use, as they become reported or known to the health care facility.
4. (4) "Department" means the Utah Department of Health and Human Services.

5. (5) "Harm scale" means a systematic method of designating a patient's level of harm that includes:

   1. (a) unsafe conditions;
   2. (b) near miss;
   3. (c) no harm;
   4. (d) additional monitoring or treatment to prevent harm;
   5. (e) temporary harm requiring intervention;
   6. (f) temporary harm requiring hospitalization;
   7. (g) permanent patient harm;

   8. (h) intervention to sustain life; or

      1. (i) patient death.
6. (6) "Health care facility" is used as defined in Subsection 26B-2-201(13).
7. (7) "Immediately post-operative" means within 24 hours after surgery, or other invasive procedure was completed, or after induction of anesthesia if surgery not completed;
8. (8) "Incident facility" means a facility where the patient safety event occurred while in the facility or immediately following discharge within a certain time period defined by specifically by the type of event from that facility.
9. (9) "Intraoperative" means during surgery.

10. (10) "Medication Error" means medication administration:

    1. (a) of a drug other than as prescribed or indicated;
    2. (b) of a dose other than as prescribed or indicated;
    3. (c) to a patient who was not prescribed the drug;
    4. (d) at a time other than prescribed or indicated;
    5. (e) at a rate other than as prescribed or indicated;
    6. (f) of an improperly prepared drug;
    7. (g) by a means other than as prescribed or indicated; or
    8. (h) unintentional administration of a drug to a patient who has a known allergy or drug interaction to the prescribed medication.
11. (11) "Near miss" means stopping or aborting a procedure for the safety of the patient.
12. (12) "Patient safety events" mean a compilation of serious, largely preventable, and harmful clinical adverse events that includes surgical events, product or device events, patient protection events, care management events, environmental events and criminal events.

KEY: hospital, sentinel event, quality improvement, patient safety

Date of Last Change: November 6, 2023

Authorizing, and Implemented or Interpreted Law: 26B-1-202(25); 26B-1-202(26); 26B-7-202(1); 26B-1-202(29); 26B-1-202(30); 26B-8-406; 26B-8-407