NQF’s list of serious reportable events’

Twenty-seven "serious reportable events" are divided into six categories on the National Quality Forum’s (NQF) new list, which it hopes will be adopted by states for uniform state-based reporting. These are the events that the NQF says should be reported to state bodies:

1. Surgical events

A. Surgery performed on the wrong body part: Defined as any surgery performed on a body part that is not consistent with the documented informed consent for that patient. Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent.

B. Surgery performed on the wrong patient: Defined as any surgery on a patient that is not consistent with the documented informed consent for that patient.

C. Wrong surgical procedure performed on a patient: Defined as any procedure performed on a patient that is not consistent with the documented informed consent for that patient. Excludes emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent.

D. Retention of a foreign object in a patient after surgery or other procedure: Excludes objects intentionally implanted as part of a planned intervention and objects present prior to surgery that were intentionally retained.

E. Intraoperative or immediately post-operative death in an ASA Class I patient: Includes all ASA Class I patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out. Immediately post-operative means within 24 hours after induction of anesthesia (if surgery not completed), surgery, or other invasive procedure was completed.

2. Product or device events

A. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility: Includes generally detectable contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product.

B. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended: Includes, but is not limited to, catheters, drains and other specialized tubes, infusion pumps, and ventilators.

C. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility: Excludes deaths associated with neurosurgical procedures known to be a high risk of intravascular air embolism.

3. Patient protection events

A. Infant discharged to the wrong person.

B. Patient death or serious disability associated with patient elopement (disappearance) for more than four hours: Excludes events involving competent adults.

C. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility: Defined as events that result from patient actions after admission to a health care facility. Excludes deaths resulting from self-inflicted injuries that were the reason for admission to the health care facility.

4. Care management events

A. Patient death or serious disability 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). Excludes reasonable differences in clinical judgment on drug selection and dose.

B. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products.

C. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility: Includes events that occur within 42 days post-delivery. Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.

D. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility.

E. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinimia in neonates: Hyperbiliru-binimia is defined as bilirubin levels >30 mg/dl. Neonates refer to the first 28 days of life.

F. Stage 3 or 4 pressure ulcers acquired after admission to a health care facility: Excludes progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission.

G. Patient death or serious disability due to spinal manipulative therapy.

5. Environmental events

A. Patient death or serious disability associated with an electric shock while being cared for in a health care facility. Excludes events involving planned treatments such as electric countershock.

B. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.

C. Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.

D. Patient death associated with a fall while being cared for in a health care facility.

E. Patient death or serious disability associated with the use of restraints or bed rails while being cared for in a health care facility.

6. Criminal events

A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider.

B. Abduction of a patient of any age.

C. Sexual assault on a patient within or on the grounds of the health care facility.

D. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the health care facility.