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NQF Adds 4 Serious Reportable Events, Updates 25

John Commins, for HealthLeaders Media, June 15, 2011

For the current endorsement project, each of the SREs has been reviewed for 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. The report focuses on identifying and specifying each event for public reporting within the applicable settings of care.

The 2011 update is designed to: 1) ensure the continued currency and appropriateness of each event in the list; 2) ensure the events remain appropriate for public accountability; and 3) provide guidance gained by implementers to those just beginning to report these events, across hospitals and for three newly specified settings of care—office-based practices, ambulatory surgery centers, and skilled nursing facilities, NQF said.

The updated serious reportable events include:

 1. Surgical or invasive procedure events:

  1. Surgery or other invasive procedure performed on the wrong site
  2. Surgery or other invasive procedure performed on the wrong patient
  3. Wrong surgical or other invasive procedure performed on a patient
  4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure
  5. Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient 

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2. Product or device events
  1. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting
  2. 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
  3. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting
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