NQF expands list of reportable events

Four new additions, 25 updates

The National Quality Forum (NQF) added four new items to its list of serious reportable events and updated another 25. The changes were the result of an endorsement project in which all the reportable events were reviewed for their applicability to various settings, including hospitals, ambulatory surgical centers, skilled nursing facilities, and office settings. Three of those — office-based practices, ambulatory surgery centers, and skilled nursing facilities — are new.

"There is real opportunity outside the hospital, and we wanted to make sure we got to that," says Helen Burstin, MD, MPH, senior vice president for performance measures.

The measures are reviewed every three years, and new events usually come as a response to a call for suggestions from the NQF. Burstin says having people on the board who come from the provider arena and from state organizations helps ensure that whatever is included, changed, or removed makes sense in the broader scheme of reporting. If states are requiring hospitals to report a certain kind of event, then the NQF list of reportable events should probably include it, too.

Burstin says 28 states and the District of Columbia use the NQF list of serious reportable events as the basis for their public reporting. "Our goal is uniformity of approach to measurement."

Along with the four new events, a couple dozen were modified in some form. For instance, the reportable event for using the wrong gas was altered because many gas cylinders no longer have interchangeable heads. The pressure ulcer item was changed to reflect updates in evidence. Another change involved removing a stand-alone reportable event of having a patient with low blood sugar because it fit in with the event on medication errors under care management.

Burstin says there were comments that came in about the changes, which are being reviewed. It is possible that in the next month or two, the published changes will be updated. If no changes are made, the next round of reviews begins in 2013. In the interim, if something arises that causes concern, NQF can address it on an ad hoc basis. Most such changes relate to unintended consequences of requirements. A few years back, a measure about giving antibiotics to pneumonia patients within four hours led to a lot of people getting antibiotics before they were officially diagnosed with pneumonia. That led to an ad hoc review and change, she says.

The new reportable events are as follows:

  • Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
  • Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
  • Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.
  • Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area.

For more information on this topic, contact:

  • Helen Burstin, Senior Vice President for Performance Measures, National Quality Forum, Washington, DC. Telephone: (202) 783-1300.

For the NQF's complete list of serious reportable events, go to: http://www.qualityforum.org/News_And_Resources