Serious Reportable Events in Healthcare: 2005-2006 Update

Purpose

In 2002, the National Quality Forum (NQF) published a report, Serious Reportable Events in Healthcare, which identified 27 adverse events that are serious, largely preventable, and of concern to both the public and healthcare providers. NQF has now formally launched the Consensus Standards Maintenance Committee on Serious Reportable Events to review the list and recommend additions or changes for Members to consider so that the set remains current and appropriate.

Background

The objective of the report and project was to establish consensus among consumers, providers, purchasers, researchers, and other healthcare stakeholders about those preventable adverse events that should never occur and to define them in a way that, should they occur, it would be clear what had to be reported. The original use of the list was intended to be as part of a federally funded, national five-state pilot project to bring order to adverse event reporting in the United States. Because the demonstration project was not realized, implementation at the state level was pursued as an alternative, and active outreach by the NQF to states was undertaken.

The original list of events was not intended to capture all events that might possibly be useful to report. Rather, the items on this list are events that are:

  • Of concern to both the public and healthcare professionals and providers.
  • Clearly identifiable and measurable, and thus feasible to include in a reporting system.
  • Of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the healthcare facility.

Scope

Maintenance of the list of events will include:

  • Review of the NQF-endorsed "never events" for continued currency and appropriateness.
  • Recommendation of new "never events" for endorsement.
  • Recommendations related to the need for additional specifications for the events.
  • Recommendations related to enhancing implementation of the list of events at the state and national level.

The NQF Process

The maintenance process, like all NQF activities, involves the active participation of representatives from across the spectrum of healthcare stakeholders. The project is guided by the Consensus Standards Maintenance Committee, which will evaluate the practices and make recommendations to refresh the currently endorsed set. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process.

Funding

Funding to support the maintenance effort will come from the NQF’s general operating funds; other sources of funding will be sought.

For more information, please call 202.783.1300 or email info@qualityforum.org.