Patient Safety: Serious Reportable Events in Healthcare 

Project Status: Completed

National Voluntary Consensus Standards for Serious Reportable Events in Healthcare

Access the Final Report: Serious Reportable Events In Healthcare—2011 Update

The Opportunity

As a portion of its contract with the Department of Health and Human Services (Contract #HHSM-500-2009-00010C), the National Quality Forum (NQF) is seeking nominations for members of three Technical Advisory Panels (TAPs). These panels will provide expertise and guidance to the Steering Committee for Serious Reportable Events (SREs) in Healthcare. This committee is updating the existing list of NQF SREs and developing an expanded listing of SREs which will be relevant for environments of patient care beyond inpatient hospital settings.

About The Project

In 2002, NQF published an initial report, Serious Reportable Events in Healthcare, which identified 27 adverse events occurring in hospitals that are serious, largely preventable and of concern to both the public and healthcare providers. 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. This report was updated in 2006, with one additional event being added. In addition, the 2006 update summarized the progress made by implementing the list and provided guidance to those engaged in implementing such reporting systems. This program is now due for review and maintenance with possible updates and additions to the listing of SREs that will be published in early 2011.

The Department of Health and Human Services (HHS) has recently recognized the importance of identifying SREs that are not specific Hospital Acquired Conditions relating to payment or reimbursement practices. There is also recognition that the SREs should be expanded into other environments of care beyond hospital settings, and that they should be relevant and applicable for these non-hospital settings. As such, the SREs will delineate the conditions or complications that are acquired by patients throughout the processes of care for a given illness, which may be managed in several different healthcare environments. The following environments of healthcare will be prioritized for the 2009 update and expansion of the SREs:

  • Ambulatory & Office-Based Surgery Centers
  • Long-Term Care Settings (including Skilled Nursing Facilities)
  • Ambulatory Non-Hospital Practice Settings (Physician Offices)


Development and maintenance of the respective listings will include:

  • Expanding the listing of SREs to be relevant and applicable in hospital settings as well as the varied non-hospital environments of patient care.
  • Bridging overlaps and complementarities of the listings with the NQF-endorsed Safe Practices and other national healthcare priorities.
  • Recommendations related to enhancing implementation of the listings at the facility, state, and national level.
  • Recommendations related to the need for additional specifications for the existing SREs.
  • Recommendations of potentially new SREs for endorsement.


This process involves the active participation of representatives from across the spectrum of healthcare stakeholders. The project will be guided by the Steering Committee for Healthcare Acquired Conditions and Serious Reportable Events, which will evaluate the practices and make recommendations to refresh the currently endorsed set. Four technical advisory panels will be formed with expertise in the occurrence of unforeseen conditions and complications in the various environments of healthcare. These panels will ensure that NQF and the Steering Committee receive relevant industry and public input and that resulting policies and standards are developed in alignment with NQF's role as a national voluntary consensus standards-setting organization. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process.

Project Funding 

This project is funded under NQF’s contract with the Department of Health and Human Services.

Related NQF Work 

Serious Reportable Events in Healthcare - 2006 Update 

Contact Information

For more information, contact Melinda Murphy, RN, MS, NE-BC, at 202-783-1300 or

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