Reporting medical errors

The problem of medical errors is not limited to Saudi Arabia or the GCC region.  In-fact it is a problem in every country in the world. Many medical errors are never reported by healthcare professionals due to fear of punishment, they could be concealed by patients and their families, perhaps feeling that reporting would be pointless. The Central Board for Accreditation of Healthcare Institutions is now instituting a system by which they will receive and study cases of serious medical errors at accredited institutions and other serious medical errors and serious incidents that must be reported. The Ministry of Health specified the following events to be reported: -

1. Abduction of any patient receiving care within a healthcare facility
2. Discharge of an infant to the wrong family
3. Discharge of a Minor or Incapacitated Patient to an unauthorized person
4. Suicide, attempted suicide, or self-harm that results in severe, temporary harm, permanent harm, or death while being cared for in a healthcare setting or within 72 hours of discharge
5. Staff Suicide, attempted suicide, or self-harm that results in severe, temporary harm, permanent harm, or death.
6. invasive diagnostic or therapeutic procedures or surgery, on the wrong patient, wrong site or side, wrong implant
7. Fertilizing wrong sperm to wrong ovum, or implant wrong embryo to wrong mother, or un unexpected damage to embryos, sperm, eggs, or frozen tissue in fertilization and infertility
8. Administration of incompatible ABO, Non-ABO of blood/ blood products, or transplantation of incompatible organs
9. Unintended retention of a foreign object in a patient after surgical/invasive procedure
10. Unexpected death of full-term newborn
11. Rape cases encountered within the premises/campus of health care
12. Assault or homicide of any patient receiving care, treatment, and services at the health care facility setting
13. Assault or homicide of visitor or watcher receiving care, treatment, and services at the health care facility setting
14. Physical and psychological violence, or homicide of a staff member, or vendor at the health care facility sitting
15. Fire, flame, or unanticipated smoke, or flashes occurring within a healthcare facility
16. Unauthorized discharge of the patient (escape) during the period of health care resulting in temporary serious harm, chronic damage or death
17. Medication error leading to death, permanent, or severe temporary harm
18. Patient death, permanent, or severe temporary harm associated with intravascular air embolism
19. Patient death, permanent, or severe temporary harm as a result of medical device breakdown or failure when in use
20. The unexpected building collapse or malfunctioning structure or overturning of any healthcare facility load bearing part of any lift or lifting equipment when in use or during installation
21. Transfusing/transplantation of contaminated blood, blood products, organ or tissue or transmission of disease result of using contaminated instrument provided by the health care facility
22. Death or serious disability associated with failure to manage/identify neonatal hyperbilirubinemia
23. Delivery of radiotherapy to the wrong body region or dose exceeds more than 25% of the total planned radiotherapy dose
24. Patient death, permanent harm, or severe temporary harm as a result of patient fall
25. Patient death, permanent harm, or severe temporary harm associated with wrong administration/connection of medical gas
26. System failure leading to service interruption and total evacuation outside health care facility
27. Unexpected death
28. Unexpected loss of a limb or function
29. Maternal death, permanent harm, or severe, temporary harm
30. MRI damage or patient or staff sever temporary harm or death associated with introduction of metallic object
31. Loss or damage to specimen or tissue biopsy after invasive procedure

As of January 2016, CBAHI accredited hospitals must report all serious accidents by filling and submitting the serious accident reporting form on CBAHI website within 5 working days from the internal notice of the serious accident (the date on which hospital management is notified of the accident). This must be followed by Root Cause Analysis (RCA) and a work plan to eliminate risks within 30 days from the date of serious accident notice. The RCA is an official process of investigations aimed at identifying the root causes of negative adverse events.

To report a sentinel event For Accredited institution, please click here 
To review the Central Board’s policy for serious medical errors, click here.
For more information about the benefits of reporting medical errors, please click here.
To review 20 tips for preventing medical errors, click here.
For inquiries, communication and more information, contact us through SERF@cbahi.gov.sa