PAE Reporting

 Preventable Adverse Events, also known as PAEs, can happen in health care. They are not supposed to happen.  An example would be surgery on the wrong body part, or a bad injury from a fall. Health care workers try hard to make sure PAEs don't happen. 

The State of Texas decided that most hospitals and surgery centers must report PAEs.  As of January 1, 2015, PAEs that happen are reported to the Department of State Health Services.

A report of Preventable Adverse Events (PAEs) that have happened will be made every six months. Please visit Facilities Reports to find these reports.

Reportable PAEs

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A report of Preventable Adverse Events (PAEs) that have happened will be made every six months. The first report was on December 1, 2015. You can find these reports at Data. Below is a list of the PAEs that will be reported.

Starting January 1, 2015

1. Surgery on the wrong body part.
2. Surgery performed on the wrong patient.
3. Wrong surgery performed on a patient.
4. Object left in patient after surgery.
5. Death of a healthy patient after surgery.
6. The release of a patient who cannot make their own decisions to the wrong person.
7. Any event where a medical gas was not given to a patient correctly (No gas, wrong gas or toxic gas).
8. Abduction of a patient while at the facility.
9. Sexual assault on a patient while at a health care facility.
10. Patient death or serious harm resulting from physical assault that happened at the health care facility.
11. Patient death or severe harm associated with a fall in a health care facility that caused a broken bone.
12. Patient death or severe harm associated with a fall in a health care facility that caused the dislocation of a joint.
13. Patient death or severe harm associated with a fall in a health care facility that caused a head injury.
14. Patient death or severe harm associated with a fall in a health care facility that caused a crushing injury.
15. Patient death or severe harm associated with a fall in a health care facility that caused a burn.
16. Patient death or severe harm associated with a fall in a health care facility.
17. Patient death or severe harm associated with getting blood in an unsafe way.
18. Patient death or severe harm resulting from losing a sample that could not be replaced.
19. Patient death or severe harm resulting from test results were not communicated or followed up on.
20. Patient death or severe harm associated with the use of restraints or bedrails.
21. Patient death or severe harm of a mom or a baby during the birth of a child after a healthy pregnancy.

 Starting January 1, 2016

1. Blood clot in a vein or a blockage in the lungs after knee replacement surgery.
2. Blood clot in a vein or a blockage in the lungs after hip replacement surgery.
3. Lung collapse when a tube is inserted into a vein.
4. A deep bed sore that develops while patient is in a health care facility. 
5. Medical order(s) given by a person pretending to be a doctor, nurse, or other provider.
6. Patient commits suicide, attempts suicide or severely harms themselves in a health care facility.
7. Patient death or severe harm after a patient leaves health care facility without telling medical staff.
8. Patient death or severe harm associated with an electric shock while in a health care facility.
9. Patient death or severe harm associated with a burn while in the health care facility.
10. Patient death or severe harm associated with taking something metal into the MRI area.

Starting January 1, 2017

1. An infection after having surgery on the spine.
2. An infection after having surgery on the shoulder.
3. An infection after having surgery on the elbow.
4. An infection after surgery to join the stomach to the intestines.
5. An infection after having surgery to re-direct food around parts of their stomach to reduce the amount of food a patient gets.
6. An infection after having surgery to make their stomach smaller.
7. An infection after implanting an electronic heart device.
8. Artificial insemination with the wrong donor sperm or egg.
9. Coma with low blood sugar.
10. High blood sugar.
11. Coma with high blood sugar and dehydration.
12. High blood sugar due to another condition.
13. High blood sugar and dehydration due to another condition.
14. Patient death or severe harm associated with using contaminated medicines or devices.
15. Patient death or severe harm associated with a device that isn't used properly.
16. Patient death or severe harm in a patient who had an air bubble in the blood while at a health care facility.
17. Patient death or severe harm associated with a medicine error.