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) 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's are events that are:

  •     Of concern to both the public and healthcare professionals and providers;

  •     Clearly identifiable and measureable;

  •     Feasible to including 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 has recently defined 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 identical to that of the NQF. These categories include:

Surgical or Invasive Procedure: Procedures incorrectly performed on the wrong site, wrong patient, or 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. Also included is patient death or serious injury as a result of air entering into the patient’s bloodstream.

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 injury caused by self-harm or associated with patient elopements (disappearances).

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, or failures in systems designated for oxygen or other gas to be delivered to a patient, or patient or staff burns, or events associated with the use of physical restraints or bedrails.

Radiologic: This new category addresses both patient or staff serious injuries or death 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 58 Serious Reportable Events in 2013:

      Surgical Events:                        4 Wrong Side Procedure
                                                            1 Wrong Surgical Procedure
                                                            5 Retained Foreign Objects
      Product or Device Events:       1 Air Embolism
      Patient Protection Events:        0 events in this category
      Care Management Events:      8 Medication Event
                                                            1 Serious injury to neonate associated with delivery
                                                            18 Falls With Injury
                                                            14 Stage III or IV Pressure Ulcers
                                                            1 Artificial insemination with wrong donor sperm
      Environmental Events:              0 events in this category
      Radiologic Events:                     4 Burns Injuries
      Criminal Events:                         1 Staff injury from physical assault

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 2013, there were over 19,000 safety events submitted by our staff, a 10% increase in safety reports as compared with the previous year 2012. From these many reported events, 58 were reported to the DPH as SREs.

TABLE 1.

SURGICAL OR INVASIVE PROCEDURE EVENTS
Surgery or other invasive procedure performed on the wrong site 4
MGH had four events of this type in 2013.
Surgery or other invasive procedure performed on the wrong patient 0
MGH had no events of this type in 2013.
Wrong surgical or other invasive procedure performed on a patient 1
MGH had one event of this type in 2013.
Unintended retention of a foreign object in a patient after surgery or other invasive procedure 5
MGH had five events of this type in 2013.
Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient 0
MGH had no events of this type in 2013.

PRODUCT OR DEVICE EVENTS
Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics 0
MGH had no events of this type in 2013.
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 0
MGH had no events of this type in 2013.
Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting 1
MGH had one event of this type in 2013.

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 2013.
Patient death or serious injury associated with patient elopement (disappearance) 0
MGH had no events of this type in 2013.
Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting 0
MGH had no events of this type in 2013.

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) 8
MGH had eight events of this type in 2013.
Patient death or serious injury associated with unsafe administration of blood products 0
MGH had no events of this type in 2013.
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 2013.
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 2013.
Patient death or serious injury associated with a fall while being cared for in a health care setting 18
MGH had eighteen events of this type in 2013.
Stage 3 or 4 Pressure Ulcers Acquired after Admission 14
MGH had fourteen events of this type in 2013.
Artificial Insemination with the Wrong Donor Sperm or Donor Egg 1
MGH had one event of this type in 2013.
Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen 0
MGH had no events of this type in 2013.
Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 0
MGH had no events of this type in 2013.

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 2013.
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 2013.
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 4
MGH had four events of this type in 2013.
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 2013.

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 2013.

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 2013.
Abduction of a patient/resident of any age 0
MGH had no events of this type in 2013.
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 2013.
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 1
MGH had one event of this type in 2013.

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 is the continued commitment to reduce patient falls and prevent falls with injury. The hospital leadership and staff implemented the Let’s Eliminate All Falls (LEAF) initiative, a comprehensive fall prevention program in 2011. Since then, a multidisciplinary team of clinicians have implemented improvements to further strengthen LEAF. During 2013, the hospital’s fall prevention committee implemented a post-fall algorithm to ensure a thorough patient evaluation is completed for any patient who sustains a fall. This improved responsive after a fall helps to quickly assess for any injury that may have resulted from the fall event.. Each fall event at the hospital continues to be reviewed by quality leaders, managers, and staff to identify strategies to avoid further patient falls. The Clinical Nurse Specialist (CNS) pressure ulcer committee has lead a number of initiatives to reduce patient’s risk of developing a pressure ulcers. One intervention has been an effort to encourage staff to complete a safety report for all newly identified pressure ulcers. This timely reporting has alerted nurses to the need for a timely CNS consultation. This has increased the focus on preventing pressure ulcers. Efforts to reduce pressure to patient’s skin continues across MGH. The Collaborative Governance Committee including staff nurses and clinical leadership have implemented projects at the inpatient unit-level across the hospital to reduce or eliminate, friction, and shearing injures to patient’s skin, while reducing maceration caused by moisture whenever possible. A multi-tiered effort to reduce skin breakdown includes introducing a combination of products that relieve pressure, protect the skin, and treat breaks in skin. Efforts by nurses to round hourly on their patients increases how frequently patients skin is assessed and patients are turned to avoid sustained pressure to the patient’s skin. 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 ) (National Quality Forum (NQF), Serious Reportable Events In Health-care—2011 Update: A Consensus Report, Washington, DC: NQF; 2011)

 

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