Serious Reportable Events in Healthcare 2011 Update
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1 Serious Reportable Events in Healthcare 2011 Update July 19,
2 Overview Purpose 2002, 2006, 2011 Facilitate uniform, comparable public reporting Enable systematic learning Ensure currency & appropriateness Provide guidance from implementers Expand to new settings of care 2
3 Major Changes in 2011 Expanded committee expertise to ensure events are relevant for the targeted areas Broadened focus to explicitly include: Hospitals Office-based practices Ambulatory surgery centers Skilled nursing facilities Expanded Implementation Guidance Added glossary to improve clarity 3
4 Criteria To qualify for the list of Serious Reportable Events in Healthcare 2011 Update events must have been determined to be unambiguous, largely if not entirely preventable, serious, and any of the following: adverse indicative of a problem in a healthcare setting s safety systems important for public credibility or public accountability Additionally, items included on the list are events that are: of concern to both the public and healthcare professionals and providers; clearly identifiable and measurable; feasible to include in a reporting system; and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the healthcare facility. 4
5 Categories of Events 6 categories essentially unchanged Surgical or Invasive Procedure Product or Device Patient Protection Care Management Environmental Potential Criminal 1 New Radiologic 5
6 Pluses & Minuses 25 existing events updated 3 events retired Hypoglycemia Kernicterus Spinal Manipulation 4 new events added 29 events for endorsement 6
7 Surgical or Invasive Procedure Wrong patient Wrong site Wrong procedure Unintended retention of foreign object Intra- or immediate post-op death of ASA Class 1 patient 7
8 Product or Device Death or serious injury associated with: Use of contaminated drugs, devices, or biologics Use or function of device in which device is used or functions other than as intended Intravascular air embolism 8
9 Patient Protection Discharge/release of patient (any age) who is unable to make decisions to unauthorized person Patient elopement Suicide, attempted suicide, self-harm w/ serious injury 9
10 Care Management Patient death or serious injury associated with: Medication error Unsafe administration of blood products Labor or delivery in low risk pregnancy mother Labor or delivery in low-risk pregnancy - neonate (new) A fall Artificial insemination with the wrong donor sperm or wrong egg 10
11 Care Management (cont.) Stage 3, Stage 4 and Unstageable pressure ulcers acquired after admission Patient death or serious injury resulting from: Irretrievable loss of irreplaceable biologic specimen (new) Failure to follow up or communicate lab, pathology, or radiology test results (new) 11
12 Environmental Patient or staff death or serious injury associated with: Electric shock during patient care process Burn from any source in course of patient care process Patient death or serious injury associated with use of physical restraints or bedrails Incident in which systems designated for oxygen or other gas contains no gas, wrong gas, or is contaminated 12
13 Radiologic Death or serious injury of patient or staff associated with metallic object in MRI area (new) 13
14 Potential Criminal Care ordered or provided by physician, nurse, pharmacist or other licensed healthcare provider impersonator Abduction of patient of any age Sexual abuse/assault on a patient or staff member within or on grounds of healthcare setting Death or serious injury of patient or staff resulting from physical assault within or on grounds of healthcare setting 14
15 Events Not Recommended Fluoroscopy dosing-related death or serious injury CLABSI-related death or serious injury Failure to rescue in surgical patients with serious treatable complications Use of an arterially misplaced CVC Diagnostic testing error-related death, serious disability or unnecessary invasive procedure Harm resulting from incorrect placement of feeding or ventilation tube Death or serious injury related to care by impaired healthcare worker 15
16 NQF Appeals Three Appeals were received The appeals addressed 5 events and also question the specificity of several definitions The appeals will be addressed over the next month 16
17 To access the updated list of serious reportable events: NQF Serious Reportable Event Update 17
18 Questions? Comments! 18
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