A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility. The National Quality Forum (NQF) coined the term to refer to "preventable, serious, and unambiguous adverse events that should never occur.” SREs are commonly referred to as "never events." An increasing number of states require that SREs are reported.
The NQF has compiled a list of 28 SREs in six categories.
Surgical events include:
• Performing a surgery on the wrong body part
• Performing a surgery on the wrong patient
• Performing the wrong surgery on a patient
• Leaving a foreign object in a patient
Product or device events include:
• Death or disability as a result of contaminated drugs or faulty devices received through a healthcare facility.
• Patient death or serious disability resulting from the wrong device used or a device functioning other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs
while in care
Patient protection events include:
• Sending an infant home with the wrong parents
• Death or serious harm suffered when a patient leaves the facility without
• Suicide, or attempted suicide that results in serious harm, while a patient in a healthcare facility
Care management events include:
• Death or serious harm as a result of a medication error, such as the wrong dosage, wrong medication or medication given to the wrong patient
• Death or serious disability as a result of being given incompatible blood or blood products
• In a low risk pregnancy, maternal death or serious harm as a result of labor or delivery in a healthcare facility
• Stage 3 or 4 pressure ulcers (bed sores) acquired during care
• Artificial insemination conducted using the wrong egg or donor sperm
Environmental events include:
• Death or serious disability as a result of electric shock
• Delivery of the wrong gas in an oxygen line
• Death or serious disability resulting of a fall while in care
• Patient death or significant disability as a result of the use of restraints or bedrails while
Criminal events include:
• Any patient care conducted by an unauthorized person
• Patient abduction
• Sexual assault of a patient while in care
• Death or serious injury of a patient or staff member as a result of an assault on the grounds of a healthcare facility.
The NQF report Safe Practices for Better Healthcare recommends 30 practices for the reduction of risk to patients.
Beyond eliminating “never events,” quality reporting in general is touted as the path to improved care delivery.
The role of health IT in safety and quality reporting.
Providers increasingly turn to clinical analytics to help identify and reduce adverse events.
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