Serious Adverse Event Provider Form

LifeWise Health Plan of Washington Serious Adverse Events Notification Form

This Department of Health adapted form can be used when present-on-admission indicators are not submitted on every applicable claim by the facility. Do not send this form if present-on-admission indicators are submitted on all applicable claims.

Please enter information in the gray-highlighted text box and submit this form to our office. Notification For LifeWise use only: must be given within 30 days of event. You may save this form or print out for your records after submitting to LifeWise.

Facility name: Notification method: Confirmation of event:

Facility contact name: Confirmation sent: LW

Phone number: assoc name rcvd: Database: Contact email:

Event date:

Event type (number):

LifeWise member ID #:

. Fax (24/7): 425-918-4332, HCDS, Subject: Adverse Events . Email your Provider Network Executive Submit by: . Mail: LifeWise Health Plan of Washington, Attn: HCDS, re: Serious Adverse Events 7001 220th St. SW, Mountlake Terrace, WA 98073-7001

Surgical Events Environmental Events

Patient death or serious disability associated with electric shock or elective 1 Surgery performed on wrong body part 19 cardioversion while being cared for in a healthcare facility

Patient death or serious disability associated with a burn incurred from any 2 Surgery performed on the wrong patient 21 source while being cared for in a healthcare facility

Patient death or serious disability associated with a fall while being cared 3 Wrong surgical procedure performed on a patient 22 for in a healthcare facility

Unintended retention of a foreign object in a patient after surgery or other 4 procedure

Products or Devices Additional (CMS-Specified) Events

Patient death or serious disability associated with the use of contaminated Catheter-associated urinary tract infection (UTI) 6 28 drugs, devices, or biologics provided by the healthcare facility Patient death or serious disability associated with the use or function of a Iatrogenic pneumothorax with venous catheterization 7 device in patient care in which the device is used or functions other than as 29 intended Patient death or serious disability associated with intravascular air embolism Surgical site infection, mediastinitis, following coronary artery bypass graft 8 30 while being cared for in a healthcare facility (CABG)

Care Management Events 31 Surgical site infection following bariatric surgery for obesity: laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery

Patient death or serious disability associated with hemolytic reaction due to Surgical site infection following cardiac implantable electronic device 13 32 the administration of ABO/HLA-incompatible blood or blood products (CIED) procedures Patient death or serious disability associated with hypoglycemia, the onset Surgical site Infection following certain orthopedic procedures: spine, neck, 15 33 of which occurs while the patient is being cared for in a healthcare facility shoulder, elbow, hip (both including deep-vein thrombosis)

Stage 3 or 4 pressure ulcers acquired after admission to a healthcare 17 facility

For additional adverse event definitions please see the CMS and National Quality Forum website s.

Adapted from the following Source: HSQA/Office of Community Health Systems/Patient Safety-Adverse Events DOH 689-004 (March 2011) 030326 (01-2014)