Serious Reportable Events

What are we measuring and why?

Since 2008, Massachusetts hospitals have been required to monitor for Serious Reportable Events (SREs) as defined by the National Quality Forum (NQF).  NQF considers an SRE 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; and

  •     Important for public credibility or public accountability.

Additionally, SRE events 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.

When an SRE is discovered, hospitals are required to report these events to the state Department of Public Health (DPH). NQF defines seven categories of SREs that include 29 specific event types – the full list of events is included in Table 1. Currently, Massachusetts’ list of reportable SREs is similar to that of the NQF. These categories include:

Surgical or Invasive Procedure: Procedures incorrectly performed on the wrong site, wrong patient, or for the wrong surgery. This also includes retained foreign objects and unexpected patient deaths during or immediately after surgery.

Product or Device: Death or serious injury from using a contaminated drug or biological product, or from a device that functions other than intended. Patient death or serious injury as a result of air entering into the patient’s bloodstream is also included.

Patient Protection: Includes the discharge or release of a patient, who can not make decisions, to other than an authorized person. Patient suicides or serious injuries caused by self-harm or associated with patient elopements (disappearances) are also included.

Care Management: This broad category includes death or serious injury from medication errors, unsafe administration of blood products, severe skin breakdown (Stage 3 or 4 pressure ulcers), or patient fall events with injury. Also, death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy or artificial insemination with the wrong donor sperm or wrong egg.

Environmental: Death or serious injury from electrical shocks during the course of a patient's care, failures in systems designated for oxygen or other gas to be delivered to a patient, patient or staff burns, or events associated with the use of physical restraints or bedrails.

Radiologic: This category addresses both patient or staff serious injuries or deaths that occur as a result of a metallic object being introduced into a Magnetic Resonance Imaging (MRI) scanner.

Potential Criminal: Any instances where staff impersonate a licensed healthcare professional, abduction of a patient, sexual abuse/assault on either a patient or staff member, or death/serious injury of a patient or staff member as a result of a physical assault on the health facility's property.

To view the SRE categories on the National Quality Forum website, CLICK HERE.

How are we doing?

The MGH reported 74 Serious Reportable Events in 2017:

DPH explicitly states that the number of SREs does not necessarily correlate with the quality or safety of the care 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 and learning from these events. The MGH has a robust safety event reporting system. Hospital leadership encourages all staff members to report adverse events, as well as events that do not actually reach the patient, which we refer to as close calls or near misses. During 2016 and 2017, there were over 21,000 safety events submitted by our staff. From these many reported events, 74 were reported to the DPH as SREs.

TABLE 1.

SURGICAL OR INVASIVE PROCEDURE EVENTS
Surgery or other invasive procedure performed on the wrong site 7
MGH had seven events of this type in 2017.
Surgery or other invasive procedure performed on the wrong patient 0
MGH had no events of this type in 2017.
Wrong surgical or other invasive procedure performed on a patient 0
MGH had no events of this type in 2017.
Unintended retention of a foreign object in a patient after surgery or other invasive procedure 2
MGH had two events of this type in 2017.
Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient 0
MGH had no events of this type in 2017.

PRODUCT OR DEVICE EVENTS
Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics 1
MGH had one event of this type in 2017.
Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended 2
MGH had two events of this type in 2017.
Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting 0
MGH had no events of this type in 2017.

PATIENT PROTECTION EVENTS
Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 0
MGH had no events of this type in 2017.
Patient death or serious injury associated with patient elopement (disappearance) 0
MGH had no events of this type in 2017.
Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting 4
MGH had four events of this type in 2017.

CARE MANAGEMENT EVENTS
Patient death or serious injury 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) 9
MGH had nine events of this type in 2017.
Patient death or serious injury associated with unsafe administration of blood products 0
MGH had no events of this type in 2017.
Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting 0
MGH had no events of this type in 2017.
Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy 1
MGH had one event of this type in 2017.
Patient death or serious injury associated with a fall while being cared for in a health care setting 16
MGH had sixteen events of this type in 2017.
Stage 3 or 4 Pressure Ulcers Acquired after Admission 22
MGH had twenty-two events of this type in 2017.
Artificial Insemination with the Wrong Donor Sperm or Donor Egg 0
MGH had no events of this type in 2017.
Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen 0
MGH had no events of this type in 2017.
Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 2
MGH had two events of this type in 2017.

ENVIRONMENTAL EVENTS
Patient or staff death or serious injury associated with an electric shock in the course of a patient care process 0
MGH had no events of this type in 2017.
Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances 0
MGH had no events of this type in 2017.
Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting 8
MGH had eight events of this type in 2017.
Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a health care setting 0
MGH had no events of this type in 2017.

RADIOLOGIC EVENTS
Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area. 0
MGH had no events of this type in 2017.

CRIMINAL EVENTS
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 0
MGH had no events of this type in 2017.
Abduction of a patient/resident of any age 0
MGH had no events of this type in 2017.
Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 0
MGH had no events of this type in 2017.
Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting 0
MGH had no events of this type in 2017.

What are we doing to improve?

All SREs 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” – a step-by-step process to verify the patient’s identity and match the procedural/surgical site before the intervention begins. Data are collected and routinely provided to leadership in each procedural area to guide improvement.

MGH is committed to reducing patient falls and associated injuries. We recently launched a new comprehensive fall prevention program called Tailoring Interventions for Patient Safety (TIPS). A multidisciplinary team of clinicians has implemented several improvements and involves patients and families in its ongoing efforts to eliminate injuries from falls. Each event is also reviewed by quality leaders, managers, and staff to learn how similar events can be avoided in the future.

The Clinical Nurse Specialist (CNS) Wound Care Task Force leads several initiatives to reduce patients’ risk of developing pressure ulcers, including a campaign that encourages staff to complete a safety report for all newly identified pressure ulcers. This information has alerted nurses to the need for a timely CNS consultation, which has increased the focus on prevention hospital-wide. The Collaborative Governance Committee, which includes staff nurses and clinical leadership, has implemented projects at the inpatient unit-level to reduce or eliminate friction and shearing injures to patients’ skin and prevent maceration caused by moisture (whenever possible). MGH has also instituted a multi-tiered effort to reduce skin breakdown, which includes introducing a combination of products to relieve pressure, protect the skin, and treat breaks.

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 something is wrong, they should feel empowered to 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 make sure that you understand the answers.
    • 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 to provide 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.
    • 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. 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 ) (National Quality Forum (NQF), Serious Reportable Events In Health-care—2011 Update: A Consensus Report, Washington, DC: NQF; 2011)

 

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