Adverse Reporting

What is defined as an event or situation that could have resulted in an accident, injury or illness?

Any adverse event or near miss should be reported to:

A process for identifying the basic or causal factor(s) that underlie the occurrence or possible occurrence of an adverse event by asking why? did an event occur is called:

Scenario: Cefazolin is mixed and hung by the admission nurse even though the patient identifies an allergy to Penicillin. During the time out, the anesthesia providers are talking and miss the identification of allergies. The Cefazolin is given. The patient has an anaphylactic reaction. The patient is stabilized and transferred to the hospital. This scenario is an example of a sentinel event.

Regarding the previous scenario, this is not a reportable incident to the state because the patient did not die.

Also in reference to the previous scenario, let's say the allergies were stated during the time out procedure and the Penicillin allergy was identified. Cefazolin was not given to the patient. This is an example of a near miss. Does it need to be reported?

Bonus question: Who is the Risk Management Officer?