Sentinel Events Reported by MTFs Air Force AF-C-10th MED GRP-ACADEMY Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AF-C-17th MED GRP-GOODFELLOW Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-20th MED GRP-SHAW Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-22nd MED GRP-MCCONNELL Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-23rd MED GRP-MOODY Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-2nd MED GRP-BARKSDALE Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-325th MED GRP-TYNDALL Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-354th MED GRP-EIELSON Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-355th MED GRP-DM Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-36th MED GRP-ANDERSEN Medication/Biological/Nutritional AF-C-436th MED GRP-DOVER Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-4th MED GRP-SJ Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-56th MED GRP-LUKE Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-579th MED GRP-BOLLING Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-59th MDW-WHASC-LACKLAND Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-628th MED GRP-CHARLESTON Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery AF-C-6th MED GRP-MACDILL Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-779th MED GRP-ANDREWS Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AF-C-78th MED GRP-ROBINS Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-7th MED GRP-DYESS Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-82nd MED GRP-SHEPPARD Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-C-92nd MED GRP-FAIRCHILD 2014 Total 2015 Total 2016 Total 2017 Total 0 0 0 0 0 0 * * 0 0 0 0 * * * 0 * 0 0 0 0 0 * 0 * 0 0 0 * 0 * 0 0 * 0 0 0 0 0 * 0 * 0 0 0 0 * 0 0 * 0 0 0 0 0 * 0 0 0 * 0 * 0 0 0 0 0 * 0 * 0 0 0 * 0 0 * 0 0 0 * 0 0 0 * 0 0 0 0 * 0 0 0 * 0 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. *there was at least one event but too few to allow reporting without endangering patient privacy. Our goal is to eliminate preventable harm. We are focused on improving patient safety. We analyze each event to develop ways to prevent harm. You may have encountered one of our strategies; for example to reduce the risk of "wrong-patient" events we ask for patient FULL NAME and DATE OF BIRTH at all visits and before all procedures. Sentinel Events Reported by MTFs Air Force Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-H-31st MED GRP-AVIANO Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery AF-H-35th MED GRP-MISAWA Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism AF-H-366th MED GRP-MT HOME Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-H-48th MED GRP-LAKENHEATH Surgical Site Infection Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AF-H-51st MED GRP-OSAN Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AF-H-633rd MED GRP LANG-EUSTIS Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AF-H-673rd-ELMENDORF Fetal: No Signs of Life Medication/Biological/Nutritional Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AF-H-96th MED GRP-EGLIN Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Unintended Retained Foreign Object AF-MC-60th MED GRP-TRAVIS Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Healthcare Associated Infection (Not Surgery/Procedure-Related; Ventilator, Other) Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia AF-MC-81st MED GRP-KEESLER Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm AF-MC-88th MED GRP-WRIGHT-PAT Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery 2014 Total 2015 Total 2016 Total 2017 Total * 0 0 0 * 0 0 0 * 0 0 0 0 * 0 0 0 0 * 0 * 0 * 0 0 0 0 0 0 * * 0 * * * 0 0 0 * 0 * 0 0 0 0 * 0 0 0 * 0 0 0 * 0 0 * 0 * * 0 0 0 0 * 0 * 0 0 0 0 0 0 0 * * 0 0 0 * 0 0 0 * * 0 * 0 * 0 * 0 0 0 0 * 0 * * * 0 0 0 0 0 0 0 0 0 0 * 0 0 * * * * * * 0 0 0 * 0 * 0 0 0 0 0 * * * 0 0 0 0 * * 0 * 0 0 * YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force Medication/Biological/Nutritional AF-MC-99th MED GRP-NELLIS Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure Army ACH BASSETT-WAINWRIGHT Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Unintended Retained Foreign Object ACH BAYNE-JONES-POLK Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Unintended Retained Foreign Object ACH BLANCHFIELD-CAMPBELL Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure ACH BRIAN ALLGOOD-SEOUL Irretrievable Loss of an Irreplaceable Biological Specimen Medication/Biological/Nutritional Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object ACH EVANS-CARSON Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Other Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure ACH IRWIN-RILEY Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure ACH KELLER-WEST POINT Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy ACH LEONARD WOOD 2014 Total 2015 Total 2016 Total 2017 Total * 0 0 0 0 0 0 0 * 0 0 * 0 0 0 * * 0 0 * * 0 0 0 * 0 0 * 0 0 0 0 0 0 * * 0 * * 0 0 * 0 0 * 0 0 0 * 0 0 0 0 0 0 * * 0 0 0 0 * * * 0 * * 0 0 0 0 0 * 0 0 * 0 0 * 0 0 0 0 0 0 * 0 0 * 0 0 0 0 * * 0 0 0 * 0 0 * 0 * 0 0 0 0 * 0 * 0 0 0 0 * 0 0 * * 0 * * 0 * 0 0 * * * * 0 0 0 0 0 0 0 0 0 0 * 0 0 0 * 0 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure ACH MARTIN-BENNING Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy ACH WEED-IRWIN Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Unintended Retained Foreign Object ACH WINN-STEWART Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fetal: No Signs of Life Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm Surgical Site Infection Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AHC GUTHRIE-DRUM Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AHC MCDONALD-EUSTIS Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Radiologic Events: Radiation Overdose, Prolonged Fluoroscopy, MRI AHC MONCRIEF-JACKSON Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape AHC MUNSON-LEAVENWORTH Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AHC R W BLISS-HUACHUCA Delay in Treatment: Lab, Path, Radiology, Referral, TX Order AHC REYNOLDS-SILL Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape Unintended Retained Foreign Object AMC BAMC-FSH Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Healthcare Associated Infection (Not Surgery/Procedure-Related; Ventilator, Other) Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape 2014 Total 2015 Total 2016 Total 2017 Total * 0 0 0 * 0 * 0 0 0 0 * 0 0 0 0 * * 0 0 0 0 0 0 * * 0 0 0 * 0 0 0 * 0 0 0 0 * 0 0 0 * * 0 0 * * 0 0 * 0 * * * 0 * 0 0 0 0 0 0 0 * 0 0 0 0 0 * * 0 0 0 0 0 * 0 0 0 0 0 0 * 0 0 0 0 * 0 0 0 0 * * 0 0 * 0 0 * 0 * * * 0 0 * 0 0 0 0 0 * 0 * * 0 7 0 0 0 0 * * * * * 0 0 0 * 0 0 * 0 0 * * * * 0 0 0 * 0 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force Suicide, Attempted Suicide or Self Harm Surgical Site Infection Unintended Retained Foreign Object Unsafe Administration of Blood or Blood Products Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AMC DARNALL-HOOD Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AMC EISENHOWER-GORDON Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Suicide, Attempted Suicide or Self Harm Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AMC MADIGAN-LEWIS Anesthesia Complications Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape Surgical Site Infection Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AMC TRIPLER-SHAFTER Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Irretrievable Loss of an Irreplaceable Biological Specimen Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object AMC WILLIAM BEAUMONT-BLISS Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Irretrievable Loss of an Irreplaceable Biological Specimen 2014 Total 2015 Total 2016 Total 2017 Total * 0 * * * 0 * * 0 * 0 0 6 0 * 0 0 * 0 * 0 0 * 0 0 0 0 * 0 * * * * * * 0 * 0 * * * * * 0 * 0 * * * * 0 * * 0 * * 0 0 0 * * * 0 0 0 * 0 0 * 0 0 0 0 * 0 0 0 0 0 * 0 0 5 * * * * * * * * 0 * * 0 0 0 * 0 * 0 0 0 0 * * * 0 0 0 * 0 0 * * 0 0 0 * 5 * 0 0 0 0 * * 0 0 * 0 7 0 * 0 0 0 0 * 8 * 0 0 * * * 0 * 0 * 0 0 * * 0 0 0 0 0 * 0 0 0 0 * 0 * 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure AMC WOMACK-BRAGG Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure BAVARIA MEDDAC-VILSECK Suicide, Attempted Suicide or Self Harm KIMBROUGH AMB CAR CEN-MEADE Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure LANDSTUHL REGIONAL MEDCEN Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure Navy NH BEAUFORT Delay in Treatment: Lab, Path, Radiology, Referral, TX Order NH BREMERTON Fetal: No Signs of Life Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Unintended Retained Foreign Object NMC CAMP LEJEUNE Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure NH CAMP PENDLETON Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure NH GUAM-AGANA Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia 2014 Total 2015 Total 2016 Total 2017 Total 0 0 * 0 0 * 0 * 0 * * * * 0 * 0 * * 0 0 0 0 * * * 0 0 0 0 0 0 0 0 * 0 0 0 * * * 0 0 0 * * 0 0 0 * * 0 * 0 0 * 0 0 0 0 0 * 0 0 * 0 0 0 * 0 * 0 * 0 0 * 0 0 0 0 * 0 * 0 0 0 0 0 0 * 0 0 0 0 0 * * 0 * 0 0 0 0 * 0 * 0 * 0 * 0 * * 0 * 0 0 0 0 0 0 * 0 0 0 0 0 * 0 0 0 0 0 * 0 * 0 0 0 * 0 0 0 0 * 0 0 * 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force NH JACKSONVILLE Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Unintended Retained Foreign Object NH NAPLES Delay in Treatment: Lab, Path, Radiology, Referral, TX Order NHC OAK HARBOR Delay in Treatment: Lab, Path, Radiology, Referral, TX Order NH OKINAWA Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy NH PENSACOLA Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Unintended Retained Foreign Object NH YOKOSUKA Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Medication/Biological/Nutritional Unintended Retained Foreign Object NHC CHERRY POINT Unintended Retained Foreign Object NMC PORTSMOUTH Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure NMC SAN DIEGO Delay in Treatment: Lab, Path, Radiology, Referral, TX Order Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Maternal (>= 20 WGA - 42 Days PP): Hemorrhage, Hysterectomy Medication/Biological/Nutritional Other Product or Device Events: Contaminated Drug/Devices/Biologics Not Used as Intended, Intravascular Air Embolism Suicide, Attempted Suicide or Self Harm Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure NCRMD 2014 Total 2015 Total 2016 Total 2017 Total 0 * * 0 * * 0 * 0 * * 0 0 0 0 0 * 0 0 0 0 * 0 0 0 0 0 * 0 * 0 * * 0 0 0 0 0 0 0 0 * * 0 * 0 * * 0 0 * 0 0 * 0 * 0 0 0 0 * 0 0 0 0 0 0 * * * * 0 0 * 0 * * 0 0 0 * * * 0 * * 0 * 0 0 0 0 0 0 * * * 0 0 * 0 * 0 * 0 0 0 0 0 * 0 * * * 0 * 0 0 * * 0 0 0 0 * 0 * 0 * * * 0 0 0 * * * * * 0 * 0 0 * 0 0 * 0 YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE. Sentinel Events Reported by MTFs Air Force DUMFRIES HEALTH CENTER Potential Criminal Events: Impersonation, Abduction, Physical Assault, Sexual Assault, Homicide, Rape FT BELVOIR COMMUNITY HOSP-FBCH Anesthesia Complications Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Fetal: No Signs of Life Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Suicide, Attempted Suicide or Self Harm Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure WALTER REED NATL MIL MED CNTR Elopement: Disappearance, AMA Environmental Events: Electronic Shock, Oxygen/Other Gas, Burn Incurred, Physical Restraints, Bed Rails Fall: Accidental, Anticipated Physiological, Unanticipated Physiological Intraoperative or Immediate Post-Op/ Post-Procedure or Surgery Medication/Biological/Nutritional Neonatal (APGAR >= 1; Birth 28 Days): Unexpected Death, Injury/Trauma, Hyperbilirubinemia Pressure Ulcers acquired After Admission/Presentation Suicide, Attempted Suicide or Self Harm Surgical Site Infection Unintended Retained Foreign Object Wrong-Site Surgery: Wrong-Patient, Wrong-Site, Wrong-Procedure Military Health System Reported Total 2014 Total 2015 Total 2016 Total 2017 Total * 0 0 0 0 * 0 0 0 * * 0 0 0 * * 0 * 0 * 0 0 0 0 * 0 0 0 * 0 0 0 * 0 0 * 0 0 * 114 0 * 0 * * * * 0 0 * * 171 0 * * * 0 0 0 0 * * 0 148 0 0 0 0 0 0 0 0 0 * * 112 Source: Defense Health Agency Patient Safety Analysis Center; retrieved on 04/16/2018 SE data shown are based on event-reported date and include all events that The Joint Commission considers reportable. Some cells have an asterisk to comply with 10 U.S.C. 1102 (Protection of individual event healthcare quality assurance data) and do not meet the definition of aggregate YOUR MILITARY HEALTH SYSTEM INTENDS TO BE A LEADER IN TRANSPARENCY. SHARING INFORMATION WITH OUR PATIENTS WILL HELP US PARTNER TOGETHER IN THEIR CARE.