Serious Reportable Events

Click here for a full description and improvement action of all events

What are we measuring and why?

Since January 2008, Massachusetts hospitals have been required to monitor for Serious Reportable Events (SREs). Serious Reportable Events, as defined by the National Quality Forum (NQF), refer to "preventable, serious, and unambiguous adverse events that should never occur”. When a SRE is discovered, hospitals are required to report these events to the state Department of Public Health (DPH). NQF has defined six categories of SREs that include 28 specific events – the full list of events is included in Table 1. Currently, Massachusetts’ list of reportable SREs is identical to that of the NQF. These categories are:

Surgical Events:  This category includes incorrect procedures, or procedures performed on the incorrect site or patient.

Product or Device Events:  This category includes death or serious disability from using a contaminated drug or biological product, or from using a device for an unintended purpose. Also included in this category is patient death or serious disability as a result of air entering into the patient’s bloodstream.

Patient Protection:  This category includes patient suicides and patient elopements (disappearances).

Care Management:  This broad category includes death or serious disability from medication errors, or administering incompatible blood products. It also includes instances of severe skin breakdown (Stage 3 or 4 pressure ulcers) when it develops after the patient has been admitted to a hospital.

Environmental Events:  This broad category includes death or serious disability from patient burns, patient falls with injury, or as a result of using restraints.

Criminal Events:  This category includes death or injury from physical assaults by patients or staff, as well as sexual assaults and patient abductions.

Why is this important?

Each year, SREs for all Massachusetts hospitals are publicly reported on the DPH’s website. The public reporting of SRE data is presented for the purposes of influencing and ultimately improving the quality of patient’s care. To that end, hospitals have been encouraged to share their action plans relating to the SREs that occur at their facilities. The MGH discloses its full list of SREs, including a short narrative about each event, on our external quality and safety website. SREs are not the only indicators of quality and safety. However, theses events do alert hospitals to the need to address areas that represent important safety concerns.

How are we doing?

The MGH reported 22 Serious Reportable Events in 2011:

      Surgical Events:                        6 events in this category
      Product or Device Events:       0 events in this category
      Patient Protection Events:       0 events in this category
      Care Management Events:     9 Stage III or IV Pressure Ulcers
      Environmental Events:             7 Falls with injury
      Criminal Events:                        0 events in this category

The DPH’s report explicitly stated that the number of SREs does not necessarily correlate with the quality or safety of the care that is provided to our patients. Instead, the public reporting of SRE data suggests that we are making progress in developing a safety culture that is supportive of sharing these events. The MGH has a robust safety event reporting system. Our hospital leadership encourages all members of the MGH staff to report adverse events. Staff is also encouraged to report events that do not actually reach the patient, which we refer to as close calls or near misses. During CY 2011, there were over 15,000 safety events submitted by our staff, a 7% increase in safety reports as compared with the previous year 2010. From these many reported events, 22 were reported to the DPH as SREs.

These 22 events reported in CY 2011 represent a 29% decrease in SREs from 2010.

TABLE 1.

SURGICAL EVENTS
Wrong Body Part 1
MGH had one event of this type in 2011.
Wrong Patient 1
MGH had one event of this type in 2011.
Wrong Procedure 0
MGH had no events of this type in 2011.
Retention of Foreign Object 4
MGH had four events of this type in 2011.
Death of ASA Class 1 Patient 0
MGH had no events of this type in 2011.

PRODUCT OR DEVICE EVENTS
Use of Contaminated Drugs, Biologics or Device 0
MGH had no events of this type in 2011.
Misuse/Malfunction of a Device 0
MGH had no events of this type in 2011.
Air Embolism 0
MGH had no events of this type in 2011.

PATIENT PROTECTION EVENTS
Infant Discharged to the Wrong Person 0
MGH had no events of this type in 2011.
Patient Elopement [Disappearance] 0
MGH had no events of this type in 2011.
Patient Suicide 0
MGH had no events of this type in 2011.

CARE MANAGEMENT EVENTS
Death or Serious Disability due to a Medical Error 0
MGH had no events of this type in 2011.
Death or Serious Disability due to a Hemolytic Reaction 0
MGH had no events of this type in 2011.
Death or Serious Disability in a Low Risk Pregnancy, Labor or Delivery 0
MGH had no events of this type in 2011.
Death or Serious Disability associated with Hypoglycemia 0
MGH had no events of this type in 2011.
Death or Serious Disability associated with Failure to Treat Hyberbilirubinemia 0
MGH had no events of this type in 2011.
Stage 3 or 4 Pressure Ulcers Acquired after Admission 9
MGH had nine events of this type in 2011.
Death or Serious Disability due to Spinal Manipulative Therapy 0
MGH had no events of this type in 2011.
Artificial Insemination with the Wrong Donor Sperm or Donor Egg 0
MGH had no events of this type in 2011.

ENVIRONMENTAL EVENTS
Death or Serious Disability associated with an Electric Shock 0
MGH had no events of this type in 2011.
Wrong Gas or Contamination in Patient Gas Line 0
MGH had no events of this type in 2011.
Death or Serious Disability associated with a Burn 0
MGH had no events of this type in 2011.
Death or Serious Disability associated with a Fall 7
MGH had seven events of this type in 2011.
Death or Serious Disability associated with use of Restraints or Bedrails 0
MGH had no events of this type in 2011.

CRIMINAL EVENTS
Care Ordered by Someone Impersonating an MD, RN, or other provider 0
MGH had no events of this type in 2011.
Abduction of a Patient 0
MGH had no events of this type in 2011.
Sexual Assault of a Patient 0
MGH had no events of this type in 2011.
Death or Injury of a Patient or Staff from Physical Assault 0
MGH had no events of this type in 2011.

These events are reported to the Massachusetts Department of Public Health. Click here for details.

Click here for a full description and improvement action of all events

What are we doing to improve?

All Serious Reportable Events are extensively reviewed and analyzed as part of our ongoing quality and safety program. For example, to reduce the risk of any wrong-site surgery or procedure being performed, the Center for Quality and Safety carefully monitors compliance with the “Universal Protocol”. The Universal Protocol is a step by step process for verifying the patient’s identity and matching the procedural/surgical site before any surgery or procedure starts. Data is collected and provided to local leadership in each of the procedural areas to help them to continue to guide staff’s improvement in this area.

Another effort at MGH to improve patient care has been to prevent patient falls with injury. The hospital implemented the Let’s Eliminate All Falls (LEAF) initiative, a comprehensive fall prevention program. This program includes frequent patient observations and guides the implementation of strategies to reduce patient falls. The clinical leadership continues to regularly assess the effectiveness of these strategies to ensure that the efforts to prevent patient falls are effective in reducing these falls.

The MGH continues to take steps to prevent patients from developing skin breakdown. A program named “Save our Skin” was recently implemented. This program aims to guide the assessment of patient’s skin and offers strategies that staff can use to prevent skin breakdown. A result of this effort has led to the purchase of new equipment and supplies to help prevent and treat skin breakdown. Another part of this program includes plans for how pressure ulcers can be treated when they do occur to prevent the breakdown from getting worse.

In summary, we are committed to improving the quality and safety of patient care across MGH.

What can you do?

Patients and their families play a key role in keeping patients safe in the hospital. If a patient or their family member thinks that something is wrong, then he or she should speak up and tell the patient’s nurse or doctor. Some helpful reminders for how you can improve your own safety while in the hospital include:

      Ask questions when you have concerns and then make sure that you understand the answers to your questions.
      Provide your nurse and doctor with all the information about your medical history.
      Bring a list of the medications that you are taking to the hospital and give that to your nurse or doctor.
      Tell your surgeon, anesthesiologist, and nurses about any allergies that you have to medications, foods, or latex products. Also, tell your doctor about any bad reaction that you have had to anesthesia in the past.
      Know that the people who greet you at the hospital, as well as your nurses and doctors, will ask you to say your name and date of birth often.
      Report any changes in your medical condition to your doctor.
      Check with your nurse before getting out of bed or using the bathroom. Ask your nurse if you are unsure of any activities, diet restrictions, or medications that your doctor has ordered for you.
      To help to avoid a fall, ask your nurse for assistance when you need to get out of bed. Review with your nurse what activities you can perform on your own and when you should call for assistance.
      Please speak up if you feel that anything is not right. We want you to speak up because your safety is our priority.

(Adapted from The Universal Patient Compact: Principles for Partnership. National Patient Safety Foundation, 2008. Available at http://www.npsf.org/for-patients-consumers/tools-and-resources-for-patients-and-consumers/universal-patient-compact )(Helpful Patient Tips (2011). National Patient Safety Foundation. http://www.npsf.org/wp-content/uploads/2011/10/Post-Discharge-Tool.pdf )

 

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