The National Quality Forum (NQF) has just updated its list of serious reportable events. The new list contains updates to the 25 events appearing on previous lists and adds four new events.
The four new events are:
· Death or serious injury of a neonate associated with labor and delivery in a low-risk pregnancy.
· Death or serious injury resulting from irretrievable loss of an irreplaceable biological specimen.
· Death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.
· Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area.
We are pleased to see the new additions, particularly the third one. We have harped on the issue of test results slipping through the cracks in numerous columns, most recently in our June 14, 2011 Patient Safety Tip of the Week “Failure to Follow Up”. And, in keeping with our mantra “stories, not statistics” we’d be remiss if we didn’t point you to a great case discussion of tests falling through the cracks (Schiff 2011). In that discussion, part of JAMA’s Clinical Crossroads series, Gordon Schiff looks at the case from the perspectives of the patient, physicians, hospitals and especially systems. When you read this article you will find yourself saying “that could have happened to me” (either as a patient or physician!).
Note that the new NQF list also now better reflects the many different venues in which patients receive care and the fact that adverse events often cross organizational boundries. Whereas historical focus has always been on events taking place in hospitals, it is now clear that serious events often occur in the outpatient setting. A recent analysis (Bishop 2011) of malpractice claims paid showed that about half of all claims paid were for events taking place outside the hospital and that major injury or death were the most common outcomes in both settings in these claims. While surgical events accounted for the most common inpatient events, diagnostic errors or failures were the most common reasons on the outpatient side.
NQF. Press Release: NQF Releases Updated Serious Reportable Events. June 13, 2011
Bishop TF, Ryan AK, Casalino LP. Paid Malpractice Claims for Adverse Events in Inpatient and Outpatient Settings. JAMA 2011; 305(23): 2427-2431
Schiff GD. Medical Error. A 60-Year-Old Man With Delayed Care for a Renal Mass.
JAMA 2011; 305(18): 1890-1898