NQF Serious Reportable Events


National Quality Forum - Serious Reportable Events*
In 2002, The National Quality Forum (NQF) created and endorsed a list of serious reportable events (SREs) to increase public accountability and consumer access to critical information about healthcare performance. There are 28 events and each is classified under 1 of 6 categories: surgical, product of device, patient protection, care management, environment, or criminal.
   
The SRE list includes both injuries caused by care management (rather than the underlying disease) and errors that occur from failure to follow standard care or institutional practices and policies. The events are largely preventable, but also very serious. The errors are of concern to the public and healthcare providers and warrant careful investigation that should be targeted for mandatory public reporting.
      
Like all NQF-endorsed™ consensus standards, the SRE list reflects a consensus among representatives of all parts of the healthcare system, including physicians, hospitals, and other healthcare providers; public and private purchasers; national, regional, state, and local groups representing consumers; accrediting bodies; supporting industries; and organizations involved in healthcare research or quality improvement.   The SRE list was updated in 2006.

Surgical Events

  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other procedure
  • Intraoperative or immediately postoperative death in an ASA Class I patient

Product or Device Events

  • Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
  • Patient death or serious disability 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 disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

  • Infant discharged to the wrong person
  • Patient death or serious disability associated with patient leaving the facility without permission
  • Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility

Care Management Events

  • Patient death or serious disability 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 disability associated with a hemolytic  reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
  • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  • Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
  • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  • Patient death or serious disability due to spinal manipulative therapy
  • Artificial insemination with the wrong donor sperm or wrong egg

Environmental Events

  • Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  • Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

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 of any age
  • Sexual assault on a patient within or on the grounds of a healthcare facility
  • Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility


*Information obtained from the National Quality Forum


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