NQF Issues New Serious Events Report
By Maureen McKinney Posted: June 20, 2011 – 12:01 am ET
New evidence about the gravest healthcare errors and where they occur has driven the National Quality Forum to update its list of “serious reportable events” for the first time in five years.
The NQF’s Serious Reportable Events in Healthcare report, used by many state organizations as a tool for public reporting of adverse events such as wrong-site surgery, patient falls and late-stage pressure ulcers, was first released in 2002 and last updated in 2006. A newly revised list includes new events and addresses patient safety in settings outside of hospitals.“The first two iterations focused on accountability among hospitals, and it was becoming increasingly clear that was a small part of the safety picture,” said Dr. Gregg Meyer, senior vice president for quality and patient safety at 907-bed Massachusetts General Hospital, Boston, and co-chair of the NQF committee that produced the updated report.
The latest list, which is open for public appeals until July 12, features 29 serious reportable events, four of which are new. For instance, one of the new events focuses on patient injury or death associated with the introduction of a metallic object into the area where an MRI is being performed. “We knew anecdotes about this happening back in 2002,” Meyer said, “but we did not appreciate the scope. Now with new evidence, we know this is a problem.”
Other newly added events include patient injury or death resulting from the loss of a biological specimen, and death or injury of a newborn baby associated with labor and delivery in a low-risk pregnancy.
Some of the adverse events that made the list in 2006 have been incorporated into other, broader categories, Meyer added. One event—death or serious disability associated with failure to identify and treat jaundice in newborns—was removed from the list because it will now be covered by a fourth new adverse event that addresses failure to follow up on test results.
“We tried to put like concepts together,” Meyer said.
Other events remained on the list but with changes. The 2006 list contains a serious reportable event, for example, related to infants being discharged to the wrong person. But in the newest list, that event reads: “Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.”
That change reflects the focus on other settings of care, such as skilled nursing facilities, office-based practices and ambulatory surgery centers, Meyer said.
Sally Tyler, a health policy analyst with the American Federation of State, County and Municipal Employees and co-chair of the NQF’s serious reportable events committee, praised the expanded focus on nonhospital settings.
“The inclusion of three new settings for the serious reportable events represents a significant stride forward in ensuring quality across the continuum of care,” Tyler said in an NQF release. “This updated report and the work that will flow from it should inspire both healthcare consumers and purchasers to be confident that improved outcomes will result.”
Comments