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Bulletin ID: No. 46 - Major Reportable Incidents

Thursday, July 10, 2008


The following MRIs MUST be reported to DMH/Office of Accountability.


1. Death

  • 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

 6. Abuse/Neglect/Exploitation

  •  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. 

7. Crime 

  • 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.

 10. Fall

  •  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

17. Fire  

  • 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