Bulletin ID: No. 46 - Major Reportable Incidents - Bulletins

MAJOR REPORTABLE INCIDENT DEFINITIONS (MRI):

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

MRI CATEGORIES	DEFINITIONS
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 1). 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. 2). 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. 3). 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. c. 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: a. on DMH or provider premise b. 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