B) ICD-9-CM Codes Surgical, diagnostic, or treatment Accident, event, circumstances, or Resulting .injury' .procedure being performed .at time of specific agent ^that caused .the injury (ICD-9 Codes 800-999,9) incident .(ICD-9 Codes 01-99.9) or event. (ICD-9 E-Codes) G) ;List any equipment used if directly involved in the incident . c ' '(Use additional sheets as necessary for complete response). - , , D) Outcome Of Incident (Please check) a' Death a Surgical procedure^erformed on the wrong site ** D Brain Damage a Wrong surgical procedure performed ** a Spinal Damage a Surgical repair of injuries or damage from a planned surgical procedure. a Surgical procedure performed on the wrong patient. ** if it resulted in: D A procedure to remove unplanned foreign objects Q Death : remaining from surgical'procedure. a Brain Damage a Spinal Damage W Any condition that required the transfer of the a Permanent disfigurement not to include the patient to a hospital. incision -scar a Fracture or dislocation of bones or joints Outcome of transfer -e.g., death, brain damage, a Limitation of neurological, physical, or sensory observation only / function. .' Name of facility to which patient was transferred: 1EK Any condition -that required the transfer 'of 'the : patient to a hospital.. - - E) Hist all persons, including license numbers if licensed, locating information and the^eapaeity'in which they were involved in this mcTdent/thiswbiiid include anesthesiologist, support staff and other'health, care providers.. , ' '\) List witnesses, including license numbers if licensed, and locating information if not listed above IV. ANALYSIS AND CORRECTIVE ACTION A) Analysis (apparent cause) ofihis incident (Use additional sheets as necessary for complete response) \\. Describe Corrective or proactive action{s) taken (Use additional sheets as necessary forcomplete response) '-.. c*^-xs/\Axi• ,~ ^P •.( V. SIGNATURE OF PH SEE SUBMITTING REPORT LICENSE NUMBER DATE REPORT COMPLETED TIME REPORTCOMPLETED ', ,•- ;..;..'.. -DH-MQA1030-12/06- - ;.'"'•' -'v; ., ':. '/Page'3 of 3'" ' STATE OF FLORIDA Rick Scott, Governor FLORIDA DEPAKTMENT OF , —f—^——-—•—• PHYSICIAN OFFICE HEALT: ADVERSE INCIDENT REPORT SUBMIT FORM TO: ' j Department of Health, Consumer Services Unit •- - 4052 Bald Cypress Way, Bin C75 -B' Tallahassee, Florida 32399-3275 I, OFFICE INFORMATION ' 6Ve lo Name of office Street Address A/ Cfty Zip Code County Telephone QSR 75V Name of Physician or Licensee Reporting License Number & office registration number, if applicable Patient's address for Physician or Licensee Reporting PATIENT INFORMATION Patient Identification Number Purpose of Office Visit *7 2. Diagnosis ICD-9 Code for description of incident Level of Surgery (II) or (III) III. INCIDENT INFORMATION Location of Incident: Incident Date and Time ''Operating Room Q Recovery Room Q Other Note: If the incident involved a death, was the medical examiner notified? a Yes a No Was an autopsy performed? a Yes a No A) Describe circumstances of the incident (narrative) {use additional sheets as necessary for complete response) DH-MQA1030-12/06 Page 1 of2 . fi^pSsSJiLTjedi bs-tsse, VUe, WrVk V5 '-i—*^ :sVis, -C csXe^T V CTT 3c-3f\ :p_U-L AM- ^X- JfXSS'^ A»_VS3 ^sxK^AiLa *6- .bpCK-\TA CLgg OPR. o-wesit. /" C/ • .\ - ( fU tY\,VW I j ^-*= ^J— TVi&ae B) ICD-9-CM Codes Sut^ical. diagnostfc, or treatment Accident, event, circumstances, or Resulting injury procedure being performed at time of specific agent that caused th'e injury (ICD-9 Codes 800-999.9) incident (1CD-9 Codes 01-99.9) or event (ICD-9 Encodes) C) List any equipment used if directly involved in the incident (Use additional sheets as necessary far complete response) D) Outcome of Incident (Please check) a Death Q Surgical procedure performed on the wrong site ** Q Brain Damage O Wrong surgical procedure performed ** a Spinal Damage Q Surgical repair of injuries or damage from a planned surgical procedure. a Surgical procedure performed on the wrong patient. ** ff it resulted in: a A procedure to remove unplanned foreign objects Q Death retraining from surgical procedure. a Brain Damage a Spinal Damage %r Any condition that required 'the transfer of the a Permanent disfigurement not to include the patient to a hospital. incision scar a . Fracture or dislocation of bones or joints Outcome of transfer - e.g., death, bcain damage, • Q' Limitation of neurological, physical, or sensory observation only f\hmitifp fp ft- 'OEsS^ffH zft) function. Name oLfacility.to which DatienWv,&s transferred: a Any condition that required the transfer of the • 3l$cK£0Ai (R, fffisoilmLi patient to a hospital.; E) List ail persons, including license numbers If licensed, locating information and the capacity in which they were involved in this incident, this would include anesthesiologist, support staff and other health care providers ffcfo**/ Of*?/)- WtZos - ) F) List witnesses, including license numbersstfll if licensedc , and locating information if not listed above IV. ANALYSIS AND CORRECTIVE ACTION A^Analysis (apparentcause) of this incident (Uao additionalsnaete asnecessaiyfor complete response B) Describe corrective or proactive actionfs) taken (Us* additional sheets as notary for c^w. resp0nso) J) -XtAM-eAXc-V &K><ten ^ot^^A- ^.A^ ^.4,^ A«to v^ ^-vO, : U^W^*^ feCaO^lOQ^ JICIAN/LICENSEE SUBMITTING REPORT LICENSE NUMBER DAI E REPdRT CCyMPLEyED ~TIME"REPORT Gd&ptETED" DH-MQA1030-12/06 ' Page 2 of2 - ICD-9-CM Codes Surgical, diagnostic, or treatment Accident event, circumstances, or Resulting injury procedure being performed at time of specific agent that caused the injury (ICD-9 Codes 800-999.9) incident (ICD-9 Codes 01-99.9) or event. (ICD-9 E-Codes) C) List any equipment used if directly involved in the incident (Use additional sheets as necessary for complete response) D) Outcome Of Incident (Please check) Q Death Q Surgical procedure performed on the wrong site ** a Brain Damage Q Wrong surgical procedure performed ** a Spinal Damage J^ Surgical repair of injuries or damage from a planned surgical procedure. Q Surgical procedure performed on the wrong patient. **if it resulted in: Q A procedure to remove unplanned foreign objects Q Death remaining from surgical procedure, a Brain Damage Q Spinal Damage ^tf^ Any condition that required the transfer of the a Permanent disfigurement not to include the patient to a hospital. incision scar Q Fracture or dislocation of bones or joints Outcome of transfer- e.g., death, brain damage, Q Limitation of neurological, physical, or sensory observation only ^^^-^icaSi ve^t-x.^ function. Name of facility to which patient was transferred: 13^ Any condition that required the transfer of the G-o-v-idL *34>nwn** M-ecStuuxfi. (jS^Jr^r patient to a hospital. '£) List all persons, including license numbers if licensed, locating information and the capacity In which -they were involved in this incident, this would Include anesthesiologist, support staff and other health care providers. i AT, F) List witnesses, Including license numbers if licensed, and locating information if not listed above IV. ANALYSIS AND CORRECTIVE ACTION A) Analysis (apparent cause) Of this Incident (Use additional sheets as nec&ssaryfor complete response) B) Describe corrective or proactive action(s) taken (Use addttional sheets as necessarylar complete response) M.i V. SIGNATURE OF PHYSICIAN/I3CENSEE SUBMITTING REPORT LICENSE NUMBER DATE REPORT COMPLETED TIME REPORT COMPLETED DH-MQA1030-12/06 Page 2 of 2 STATE OF FLORIDA DOH Consumer Services Rick Scott, Governor SEP 1 k 2015 PHYSICIAN OFFICE ADVERSE INCIDENT REPORT SUBMIT FORM TO: Department of Health, Consumer Services Unit 4052 Bald Cypress Way, Bin C75 Tallahassee, Florida 32399-3275 OFFICE INFORMATION lop Zip Code County License Number & office registration number, If applicable Date of Office Visit Patient Identification Number Buraose of Offlc Visit Diagnosis CodefDnSescriptian of incident Level of Surgery (II) or (111) 111. INCIDENT INFORMATION <9^- 2QfS~~ |.'St^QOP*A Location of Incident: Incident Date and Time [H Operating Room [Recovery Room [Hother Note: If the incident involved a death, was the medical examiner notified? QYes rj No Was an autopsy performed? nYes n No A) Describe circumstances of the incident (narrative} (use additional sheets as necessary for complete response) DH-MQA1030-12/06 Page 1 of2 DOB I DOS'9/9/2015 MR# 7400132 Pt referred here today for LLE arteriogram with possible endovascular intervention. Arteriogram was performed. No interventions done. Pt developed post procedure hematoma (after mynx closure device failed). Dr aware and direct pressure applied. Hematoma -stable and pt taken to post op area. Vitals and site monitored as per protocol. Pt continuously instructed to keep- rt leg straight., Approx l:10pm, pt noted to be lying on side with rt leg bent. Upon assessment of site, dressing found to be saturated with blood. Direct pressure held for approx 10 minutes. Drsg carefully removed and gel foam placed at site which was oozing slightly. Hematoma assessed and was noted to be enlarging distally. Pressure held again. BP taken and noted to be 97/44. HR74. Sats 94% on r/a. o2 immediately applied and satsto 100%. During this time that pressure was being applied to groin, pt's bp dropped to70's, pt c/o nausea, IVF's opened wide. LIP made aware of status and advised to apply direct pressure and if BP continues to drop, send to Westside ER. Continuously 1:1 monitoring was maintained. Pressure would sustain to acceptable parameters. EMS activated. LIP informed. Pt taken to