Claim Reporting Guidelines

Kari Adams

The following situations should be promptly reported to Physicians Insurance:

  • Unexpected brain damage following any treatment or procedures:
  • Any surgical procedure performed on the wrong patient or at the wrong site.
  • Cardiac arrest in the operating or recovery room resulting in unexpected death, brain damage, or other serious injury to the patient.
  • Suicide attempt resulting in death or serious injury to the patient.
  • Misdiagnosis in the Emergency Department resulting in death or permanent serious injury to the patient. Death within 48 hours following discharge from the Emergency Department.
  • Anesthesia complications resulting in coma, death, paralysis, or other serious injury.
  • Unexpected amputation due to poor outcome of any treatment or procedure.
  • Second- or third-degree burns as a result of any treatment or procedure.
  • Unexpected return to surgery during the same admission, regardless of reason.
  • Obstetrical occurrences:
    • Maternal or neonatal death.
    • Infants with five-minute Apgar scores of less than six.
    • Infants born at less than 34 weeks in hospitals without NICU or neonatology coverage.
    • Infants born at greater than 34 weeks transferred to any NICU.
    • Term infants that experience seizures before discharge.
  • Unexpected patient deaths:
    • Occurring from slips or falls, medication error, or equipment failure.
    • Following usually non-fatal procedure, i.e., cholecystectomy in 30 year-old healthy person.
  • Incidents resulting in impaired patient/visitor functioning or injury:
    • Slips or falls resulting in fracture, sprain, head injury, etc.
    • Transfusion error/serious reaction; i.e., wrong type of blood infused, given to the wrong patient.
    • Major IV therapy errors; i.e., wrong rate resulting in overloading/under infused, tissue/vein damage, wrong solution.
  • Major biomedical device failure/ damage resulting in injury or having the potential for injury to a patient or visitor. This is also important for compliance with the Safe Medical Devices Act (SMDA).
  • Equipment or supply defect or damage resulting in injury to a patient. SMDA reporting requirement, as well.
  • Neurological deficit not present on admission (exception: transitory deficit resolved by the time of discharge).
  • Organ or system failure not present on admission (exception: patient admitted in critical condition or terminal condition).
  • Patient or family says that they will sue.
  • Receipt of demand letter from patient or attorney.
  • Request for records by an attorney unless you know it regards a situation not directly involving your medical care, such as a patient involved in a motor vehicle accident or Workers’ Compensation claim.
  • Lawsuit.