Bulletin ID: No. 46 - Major Reportable Incidents
MAJOR REPORTABLE INCIDENT DEFINITIONS (MRI):
The following MRIs MUST be reported to DMH/Office of Accountability.
- Death of a currently enrolled DMH consumer
Death of an employee during his or her tour of duty
2. Serious Physical Injury
- Bodily harm or impairment to a consumer at a service site or staff member on duty which requires medical or dental treatment beyond first aid.
3. Medical Emergency
- Any unplanned or unanticipated medical event, that requires hospitalization or an emergency room visit, including an adverse reaction to medication, that occurs to an employee on duty or a consumer at a service site or residence
- Any event that requires 911 ambulance calls.
4. Psychiatric Emergency
- Any event that results in an FD12 being written and requires transportation by Metropolitan Police Department to a hospital emergency department or Comprehensive Psychiatric Emergency Program
5. Physical Assault
- A physical attack using force or violence upon a consumer or staff member
Abuse—alleged, suspected, or actual physical, mental, or emotional harm or threat of harm to life and safety of a consumer, employee, or any other person
- Physical abuse—physical contact with, or handling of, a consumer with more force than is reasonably necessary to ensure the safety of the consumer or others.
- Sexual abuse—any sexual or attempted sexual activity between an employee and consumer, a consumer and a non consenting consumer, or between a consumer and another person when the consumer does not or cannot give consent.
- Psychological or emotional abuse—use of verbal or nonverbal expression or other action in the presence of a consumer that subjects the consumer to ridicule, humiliation, contempt, scorn, harassment, threats of punishments, dehumanization, wrongful manipulation, or social stigma.
- Neglect—a failure to act by an employee that impairs, or creates a substantial risk of impairment to, the well being of a consumer.
- Exploitation—misuse of a consumer or of his/her resources for one’s profit, advantage, or gratification.
- Any event in which a consumer is arrested for perpetrating a crime under District of Columbia or Federal law. Crimes include, but are not limited to, activities such as arson, assault, homicide, possession of a deadly weapon, possession or sale of narcotics, theft, robbery, and sexual offense.
- Any event in which a consumer is a victim of a crime.
8. Seclusion and Restraint
- Seclusion—the involuntary confinement of a consumer in a room or area where the consumer is physically prevented from leaving, or believes that he or she cannot leave at will.
- Restraint—any manual or physical method, use of drugs as a restraint, mechanical device, material, equipment that immobilizes or reduces the ability of a consumer to move his or her arms, legs, body, or head freely.
9. Suicide Attempt
- Self-inflicted actions that put the consumer’s life at risk, the goal to end one’s life; may or may not have resulted in injury.
- The unintended and sudden loss of an upright or erect position resulting in a person coming to rest on the ground or floor on the property of a provider or DMH
11. Reportable Disease
- A disease or condition that must be reported to public health authorities at the time of diagnosis due to mandatory reporting law.
12. Medication Error
A situation in which an error in prescribing, dispensing, administering, or transcribing medication occurs.
- Administration to the wrong consumer
- Incorrect administration
- Documentation error
- Physician or pharmacy error
- Any missed medication when the consumer is present in the community residential facility (CRF)
13. Elopement (Unauthorized leave—UL)
A situation in which a consumer fails to return:
- to Saint Elizabeths Hospital after a pass or privileges has expired, or
- to the CRF after curfew.
- A situation in which the consumer is first identified as missing.
14. Contraband Illegal drugs and weapons found:
- on DMH or provider premise
- in a community residential facility
15 . Vehicular Accident
- Any vehicle accident that occurs while the staff is on duty resulting in serious injury of the employee or other person.
- Any vehicle accident (minor or major) that involves a District of Columbia Government vehicle.
- Any vehicle accident (minor or major) that occurs when a DMH consumer is a passenger.
16. Security Breach
- Any facility, required to be locked, that has faulty locks or security equipment.
- Any inappropriate release of a consumer’s protected health information.
- Any theft of DMH equipment
- Any theft occurring on DMH property
- At any DMH occupied, licensed, certified, or contracted residential, treatment, or office facility.
- Any fire that results in serious injuries or is of a suspicious nature
- Any fire that causes property damage rendering the facility or part thereof unusable