NQF Updates List of Serious Reportable Events

The National Quality Forum (NQF)—a voluntary consensus standards-setting organization under contract with the Department of Health and Human Services (HHS)—recently approved for endorsement a list of 29 serious reportable events (SREs) in health care. Twenty-five of the events were updated from a 2006 endorsement and four are completely new events. The complete list of SREs is outlined in the forthcoming report “Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report.”

“Tens of thousands of lives are forever changed each year as a result of health care errors,” said Janet Corrigan, NQF president and CEO. “This newly expanded list of serious reportable events across multiple settings provides a critical opportunity to learn from mistakes and take swift action to improve patient safety.”

SREs are preventable errors and events, such as wrong-site surgery, stage 3 or 4 pressure ulcers acquired post-admission, patient falls, and serious medication errors. More than half of the states use the NQF-endorsed list of SREs in their public reporting programs.

For this latest endorsement, the NQF says each of the SREs has been reviewed in terms of its applicability to four specific settings of care: hospitals, outpatient or office-based surgery centers, skilled nursing facilities, and ambulatory practice settings, specifically office-based practices.

Here’s the list of 2011 new and updated SREs endorsed by the NQF:

  1. SURGICAL OR INVASIVE PROCEDURE EVENTS
    • Surgery or other invasive procedure performed on the wrong site
    • Surgery or other invasive procedure performed on the wrong patient
    • Wrong surgical or other invasive procedure performed on a patient
    • Unintended retention of a foreign object in a patient after surgery or other invasive procedure
    • Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient
  2. PRODUCT OR DEVICE EVENTS
    • Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting
    • Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
    • Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting
  3. PATIENT PROTECTION EVENTS
    • Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
    • Patient death or serious injury associated with patient elopement (disappearance)
    • Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting
  4. CARE MANAGEMENT EVENTS
    • Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
    • Patient death or serious injury associated with unsafe administration of blood products
    • Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting
    • (NEW) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
    • Patient death or serious injury associated with a fall while being cared for in a health care setting
    • Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a health care setting
    • Artificial insemination with the wrong donor sperm or wrong egg
    • (NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
    • (NEW) Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
  5. ENVIRONMENTAL EVENTS
    • Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a health care setting
    • Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances
    • Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting
    • Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a health care setting
  6. RADIOLOGIC EVENTS –(NEW) Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area
  7. POTENTIAL CRIMINAL EVENTS
    • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
    • Abduction of a patient/resident of any age
    • Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
    • Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting

The public has 30 days to appeal the final decision to endorse a voluntary consensus standard. Any party may request reconsideration of the recommendations, in whole or in part, by notifying NQF in writing via email no later than July 12 at 6 pm ET to appeals@qualityforum.org.

Source: NQF press release, issued June 13

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