NQF Adds 4 Serious Reportable Events, Updates 25

The National Quality Forum board has announced that it has approved for endorsement a list of 29 serious reportable events in healthcare. The list includes four new events, along with 25 updated events from an earlier endorsement in 2006.

The four new serious reportable events are:

• Radiologic events that cause the death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area;
• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy;
•  Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen, and;
• Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results. 

The recommendations are outlined in the report Serious Reportable Events in Healthcare–2011 Update: A Consensus Report. The full list of events will be available for a 30-day public appeals process closing July 7. 

 “Tens of thousands of lives are forever changed each year as a result of healthcare errors,” said Janet Corrigan, president/CEO of the National Quality Forum said in a media release. “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.”   

The first NQF-endorsed list of Serious Reportable Events in Healthcare was released in 2002 as a set of events that might form the basis for a national state-based reporting system. This uniform approach to measurement helps to drive overall national improvement in patient safety. Currently, more than half of states use the NQF-endorsed list of SREs in their public reporting programs.

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 

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

1. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
2. Patient death or serious injury associated with patient elopement (disappearance)
3. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

1. 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)
2. Patient death or serious injury associated with unsafe administration of blood products
3. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
4. (NEW) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
5. Patient death or serious injury associated with a fall while being cared for in a healthcare setting
6. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting
7. Artificial insemination with the wrong donor sperm or wrong egg
8. (NEW) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
9. (NEW) Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 

1. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
2. 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
3. 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 healthcare setting
4. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

A. (NEW) Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

1. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
2. Abduction of a patient/resident of any age
3. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
4. 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