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NEW YORK CODES, RULES AND REGULATIONS
TITLE 10. DEPARTMENT OF HEALTH
CHAPTER V. MEDICAL FACILITIES
SUBCHAPTER A. MEDICAL FACILITIES--MINIMUM STANDARDS
ARTICLE 2. HOSPITALS
PART 405. HOSPITALS--MINIMUM STANDARDS
Date:
08/31/2009
Document:
ยง 405.8 Incident reporting
(a) Any incident required to be reported pursuant to subdivision (b) of this section shall be reported to the department's Office of Health Systems Management on a telephone number maintained for such purpose. Hospitals shall report such incidents within 24 hours of when the incident occurred or when the hospital has reasonable cause to believe that such an incident has occurred and shall take no more than seven calendar days to determine whether an incident defined in paragraph (b) (1) of this section is reportable and subject to the requirements of this section. The hospital shall give written notification within seven calendar days of the initial notification. This notification shall be submitted in a format specified by the department and shall record the nature, classification and location of the incident; medical record numbers of all patients directly affected by the incident; the full name and title of physicians and hospital staff directly involved in the incident as well as their license, permit, certification or registration numbers; the effect of the incident on the patient; follow-up treatments and evaluations planned; the expected completion date for the hospital's investigation and identification information required by the department.
(b) Incidents to be reported are:
(1) patients' deaths in circumstances other than those related to the natural course of illness, disease or proper treatment in accordance with generally accepted medical standards. Injuries and impairments of bodily functions, in circumstances other than those related to the natural course of illness, disease or proper treatment in accordance with generally accepted medical standards and that necessitate additional or more complicated treatment regimens or that result in a significant change in patient status, shall also be considered reportable under this subdivision;
(2) fires or internal disasters in the facility which disrupt the provision of patient care services or cause harm to patients or personnel;
(3) equipment malfunction or equipment user error during treatment or diagnosis of a patient which did or could have adversely affected a patient or personnel;
(4) poisoning occurring within the facility;
(5) patient elopements and kidnappings;
(6) strikes by personnel;
(7) disasters or other emergency situations external to the hospital environment which affect facility operations; and
(8) unscheduled termination of any services vital to the continued safe operation of the facility or to the health and safety of its patients and personnel, including but not limited to the termination of telephone, electric, gas, fuel, water, heat, air conditioning, rodent or pest control, laundry services, food, or contract services.
(c) The hospital shall conduct an investigation of incidents described in paragraphs (b)(1)-(6) of this section and those incidents in paragraphs (7)-(9) deemed appropriate by the department.
(d) The hospital shall provide a copy of its investigative report to the area administrator within 24 hours of its completion. This report shall document all hospital efforts to identify and analyze the circumstances surrounding the incident and to develop and implement appropriate measures to improve the overall quality of patient care. This report shall contain all information required by the department including:
(1) an explanation of the circumstances surrounding the incident;
(2) an updated assessment of the effect of the incident on the patient(s);
(3) a summary of current patient status including follow-up care provided and post-incident diagnosis;
(4) a chronology of steps taken to investigate the incident that identifies the date(s) and person(s) or committee(s) involved in each review activity;
(5) the identification of all findings and conclusions associated with the review of the incident;
(6) summaries of any committee findings and recommendations associated with the review of the incident; and
(7) a summary of all actions taken to correct identified problems, to prevent recurrence of the incident and/or to improve overall patient care and to comply with other requirements of this Part.
(e) This section does not replace other reporting required by this Part.
(f) Nothing in this section shall prohibit the department from investigating any incident included in subdivision (b) of this section.
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