Patient Safety: Serious Reportable Events:

Care Management Events

Partners Hospitals are required to report:

• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy
• Stage 3 or 4 pressure ulcers acquired after admission to the healthcare facility
• Artificial insemination with the wrong donor sperm or wrong egg
• Patient death or serious disability associated with:
  • A medication error
  • A hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products
  • Hypoglycemia (low blood sugar), the onset of which occurs while the patient is being cared for in a healthcare facility
  • Failure to identify and treat hyperbilirubinemia (kernicterus) in neonates
  • Spinal manipulative therapy

While this category of events attempts to capture a wide variety of patient care scenarios, in 2008 the Partners acute care inpatient hospitals reported a total of three events in this category. All 3 reports concerned patients who acquired pressure ulcers during their hospital stay. Preventing pressure ulcers in very sick patients who, because of their illness or their treatment, experience immobility is a very challenging problem. The Partners Chief Nurses Council directs and advises the work of the wound care nurses from across the system to improve the way we assess patients for the risk for developing pressure ulcers as well the way we treat these wounds. Their work is focused on identifying and educating bedside nurses on effective prevention strategies, sharing best practices, standardizing treatment modalities across the system.

Click on the numbers to see more information and event descriptions.

CARE MANAGEMENT EVENTS	BWH	MGH	FH	NWH	NSMC	Total Partners
Death or Serious Disability Due to a Medication Error	0	0	0	0	0	0
Death or Serious Disability Due to a Hemolytic Reaction	0	0	0	0	0	0
Death or Serious Disability In a Low-Risk Pregnancy, Labor or Delivery	0	0	0	0	0	0
Death or Serious Disability Associated with Hypoglycemia	0	0	0	0	0	0
Death or Serious Disability Associated with Failure to Treat Hyperbolirubinemia	0	0	0	0	0	0
Stage 3 Or 4 Pressure Ulcers Acquired After Admission	3	0	0	0	0	3
Death or Serious Disability Due to Spinal Manipulative Therapy	0	0	0	0	0	0
Artificial Insemination with the Wrong Donor Sperm or Donor Egg	0	0	0	0	0	0
Total Care Management Events:	3	0	0	0	0	3

BWH = Brigham and Women's Hospital; MGH = Massachusetts General Hospital;
FH = Faulkner Hospital; NWH = Newton-Wellesley Hospital; NSMC = North Shore Medical Center

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