The National Quality Forum (NQF) has recently published its proposed new Serious Reportable Events (SREs).  These are often used as a foundation by CMS, states, and private payers for public reporting and commonly linked to incentive or disincentive payment policies.  Although there were only four new measures added to the SREs, the biggest change lies in the expansion of the measures from the hospital setting to also encompass other health care providers.  The measures are also seeking to promote coordination of care as demonstrated by the additional Care Management measures, and addressing accountability beyond the inpatient stay.

The proposed measures are noted below:

SURGERY

1. Surgery or other invasive procedure performed on the wrong site (expanded to apply to other care settings).

2. Surgery or other invasive procedure performed on wrong patient:

3. Wrong surgical procedure or other invasive procedure performed on a patient

4. Unintended retention of a foreign object in a patient after Sx or other invasive procedure.

5. Intraoperative or immediately post-operative/post-procedure death in ASA Class I patient.

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.  Modified to clarify detectability.  Is development of disease or threat of disease that changes risk status, requiring monitoring not otherwise needed.

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.  Failure to properly clean, maintain or misuse device that exposes patient to disease or injury.

3. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting.  Exclusion for Sx where head above heart to reduce venous pressure for adults and pediatrics.

PATIENT PROTECTION EVENTS

1. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.  Used to be limited to infants.

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

CARE MANAGEMENT EVENTS

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

ENVIRONMENTAL EVENTS

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

RADIOLOGIC EVENTS -(NEW) 

1. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

 POTENTIAL CRIMINAL EVENTS

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

Please contact us if you would like a more thorough analysis of these SREs or how your product will be impacted by these changes.