The National Quality Forum has finalized its list of 29 serious reportable events.
NQF's endorsed serious reportable events were created to facilitate and encourage uniform and comparable public reporting and learning from adverse events. For instance, many states use NQF's recommendations for their respective public reporting programs. The measures can be applicable to a variety of settings, including hospitals, office-based surgery centers and skilled nursing facilities. For more detailed information, please read NQF's 2011 report on serious reportable events here.
The 29 endorsed events are as follows:
1. Surgical or Invasive Procedure Events
1A. Surgery or other invasive procedure performed on the wrong site
1B. Surgery or other invasive procedure performed on the wrong patient
1C. Wrong surgical or other invasive procedure performed on a patient
1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure
1E. Intraoperative or immediately postoperative/post-procedure death in an ASA Class 1 patient
2. Product or Device Events
2A. Patient death or serious injury associated with the use of contaminated drugs, devices or biologics provided by the healthcare setting
2B. 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
2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting
3. Patient Protection Events
3A. Discharge or release of a patient/resident of any age, who is unable to make decisions
3B. Patient death or serious injury associated with patient elopement
3C. Patient suicide, attempted suicide or self-harm that results in serious injury while being cared for in a healthcare setting
4. Care Management Events
4A. Patient death or serious injury associated with a medication error
4B. Patient death or serious injury associated with unsafe administration of blood products
4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting
4F. Any Stage 3, Stage 4 and unstageable pressure ulcers acquired after admission or presentation to a healthcare setting
4G. Artificial insemination with the wrong donor sperm or wrong egg
4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results
5. Environmental Events
5A. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas or are contaminated by toxic substances
5C. 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
5D. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting
6. Radiologic Events
6A. 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
7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed healthcare provider
7B. Abduction of a patient/resident of any age
7C. Sexual abuse or assault on a patient or staff member within or on the grounds of a healthcare setting
7D. Death or serious injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a healthcare setting
NQF's endorsed serious reportable events were created to facilitate and encourage uniform and comparable public reporting and learning from adverse events. For instance, many states use NQF's recommendations for their respective public reporting programs. The measures can be applicable to a variety of settings, including hospitals, office-based surgery centers and skilled nursing facilities. For more detailed information, please read NQF's 2011 report on serious reportable events here.
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The 29 endorsed events are as follows:
1. Surgical or Invasive Procedure Events
1A. Surgery or other invasive procedure performed on the wrong site
1B. Surgery or other invasive procedure performed on the wrong patient
1C. Wrong surgical or other invasive procedure performed on a patient
1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure
1E. Intraoperative or immediately postoperative/post-procedure death in an ASA Class 1 patient
2. Product or Device Events
2A. Patient death or serious injury associated with the use of contaminated drugs, devices or biologics provided by the healthcare setting
2B. 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
2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting
3. Patient Protection Events
3A. Discharge or release of a patient/resident of any age, who is unable to make decisions
3B. Patient death or serious injury associated with patient elopement
3C. Patient suicide, attempted suicide or self-harm that results in serious injury while being cared for in a healthcare setting
4. Care Management Events
4A. Patient death or serious injury associated with a medication error
4B. Patient death or serious injury associated with unsafe administration of blood products
4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting
4F. Any Stage 3, Stage 4 and unstageable pressure ulcers acquired after admission or presentation to a healthcare setting
4G. Artificial insemination with the wrong donor sperm or wrong egg
4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results
5. Environmental Events
5A. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting
5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas or are contaminated by toxic substances
5C. 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
5D. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting
6. Radiologic Events
6A. 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
7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed healthcare provider
7B. Abduction of a patient/resident of any age
7C. Sexual abuse or assault on a patient or staff member within or on the grounds of a healthcare setting
7D. Death or serious injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a healthcare setting
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National Quality Forum Releases 21 Endorsed Surgical Care Measures
NQF Releases Pressure Ulcer Prevention and Management Framework