Sentinel events to reportable ones
Sentinel events to reportable ones
Now that you’ve gotten used to the idea of sentinel events, get ready for the state equivalent: the list of "serious reportable events" recently adopted by the National Quality Forum (NQF) in Washington, DC.
The list is similar to, but entirely separate from, the sentinel events list used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The NQF, which developed the serious reportable events list, changed the name from "never events" because that sounded too harsh and allowed no flexibility in identifying the incidents. The NQF board recently approved the list of serious reportable events and will pass it on to other health care organizations for implementation.
Individual states will determine how and when to use the serious reportable events list, says John Colmers, a program officer at the Milbank Memorial Fund, an endowed national foundation in New York City that works with decision makers in the public and private sectors on issues of policy for health care and public health. Mr. Colmers worked with the NQF to develop the serious reportable events list and says the project was an outgrowth of the Institute of Medicine’s (IOM) report on medical errors, To Err is Human. That report called for a state-based system for reporting serious medical errors.
"The IOM study anticipated a two-tiered system for reporting medical errors," Mr. Colmers says. "One would be a mandatory system for reporting the most serious and egregious events at a state level. The second, and considered by IOM the most important, is a system of voluntary reporting."
The serious reportable errors list can be used for developing both mandatory reporting requirements and encouraging voluntary reporting. The Centers for Medicare & Medicaid Services (CMS), and the Agency for Health Care Policy and Research (AHCPR) funded the research. Colmers says the NQF’s job was to develop the list and then hand it over to CMS and the AHCPR for implementation.
The list looks like another version of the Joint Commission’s sentinel events but drawn up by a different committee. Critics are suggesting that the NQF’s new list duplicates the sentinel event system and will only create a dual track of reporting with unnecessary and redundant work.
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