Report Card:

Serious Reportable Events

Beginning in 2002, the National Quality Forum, in collaboration with healthcare consumers and providers, identified and endorsed a list of 28¹ events in healthcare known as Serious Reportable Events. The 28 events were chosen, based, in large part, on the following criteria:

• The event is of concern to both the public and healthcare professionals.
• The event is clearly identifiable and measurable.
• The event is serious and usually preventable.
• And the event is important for public accountability.

The NQF list of Serious Reportable Events is intended to be part of a series of consensus standards for national patient safety and to be used in conjunction with the NQF Safe Practices for Better Healthcare. Many states, hospitals, and healthcare systems are using the NQF endorsed consensus standards to promote evidenced based safety initiatives, encourage learning, and foster improvement.

Beginning in January 2008, all Massachusetts hospitals were required to collect and report occurrences of Serious Reportable Events to the Massachusetts Department of Public Health. The Partners hospitals have been collecting and reporting the NQF endorsed Serious Reportable events since 2007. We continue to look for ways to make our facilities and patient environments as safe as possible. Read on to learn more about how we are working together to prevent these events.

¹In 2002, the NQF identified 27 events. In 2006, another event, “Insemination with the wrong donor sperm or donor egg” was added for a total of 28 Serious Reportable Events.

Click on any event or category name to see more information.

» Show Individual Hospital Scores Table
SURGICAL EVENTS    Click here to read more about Eliminating Surgical Serious Reportable Events	See Category Detail Click here for more information on this category of events	Total Partners
Wrong Body Part		4
Wrong Patient		0
Wrong Procedure		1
Retention of a Foreign Object		4
Death of ASA Class 1 Patient		0
PRODUCT OR DEVICE EVENTS	See Category Detail Click here for more information on this category of events	Total Partners
Use of Contaminated Drugs, Biologics or Device		0
Misuse/Malfunction of a Device		1
Air Embolism		1
PATIENT PROTECTION EVENTS	See Category Detail Click here for more information on this category of events	Total Partners
Infant Discharged to the Wrong Person		0
Patient Elopement		0
Patient Suicide		0
CARE MANAGEMENT EVENTS	See Category Detail Click here for more information on this category of events	Total Partners
Death or Serious Disability Due to a Medication Error		0
Death or Serious Disability Due to a Hemolytic Reaction		0
Death or Serious Disability In a Low-Risk Pregnancy, Labor or Delivery		0
Death or Serious Disability Associated with Hypoglycemia		0
Death or Serious Disability Associated with Failure to Treat Hyperbolirubinemia		0
Stage 3 Or 4 Pressure Ulcers Acquired After Admission		3
Death or Serious Disability Due to Spinal Manipulative Therapy		0
Artificial Insemination with the Wrong Donor Sperm or Donor Egg		0
ENVIRONMENTAL EVENTS    Click here to read more about Reducing Patient Falls	See Category Detail Click here for more information on this category of events	Total Partners
Death or Serious Disability Associated With an Electric Shock		0
Wrong Gas or Contamination in Patient Gas Line		0
Death or Serious Disability Associated With a Burn		4
Death or Serious Disability Associated With a Fall		36
Death or Serious Disability Associated With the Use of Restraints or Bedrails		0
CRIMINAL EVENTS	See Category Detail Click here for more information on this category of events	Total Partners
Care Ordered by Someone Impersonating an MD, RN, or Other Provider		0
Abduction of a Patient		0
Sexual Assault of a Patient		0
Death or Injury of a Patient or Staff From Physical Assault		0

Partners HealthCare Source: Partners Serious Reportable Events Taskforce
Data Period: January 1, 2008 - December 31, 2008