Patient Safety: Serious Reportable Events:

Environmental Events

The NQF endorsed Serious Reportable Environmental Events include:

• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
• Patient Death or Serious Disability associated with
  • An electric shock or electric cardioversion while being cared for in a healthcare facility.
  • A burn incurred from any source while being cared for in a healthcare facility.
  • A fall while being cared for in a healthcare facility.
  • The use of restraints or bedrails while being cared for in a healthcare facility.

The most frequently reported Serious Reportable Event in 2008 at Partners hospitals was Patient death or serious disability associated with a fall while being cared for in a healthcare facility.

Patient harm related to falls in the hospital is a serious and vexing problem. At Partners, the Chief Nursing Officers oversee and advise the work of hospital based falls reduction committees as well as the research projects aimed at developing interventions which are aimed at reducing or preventing falls. In addition, each report of a patient fall with serious harm is examined for factors that could have prevented the fall. System-wide, new methods of communicating a patient’s risk for falling as well as engaging staff, patients, and family members in preventing falls in the hospital are being developed and employed.

While we report falls elsewhere in this site as well as to other care improvement organizations locally and nationally, this report includes only those events resulting in patient death or serious disability¹ related to a fall.

¹ Serious Disability related to a fall is inconsistently interpreted by the National Quality Forum, Massachusetts Department of Public Health, and other states. Working with and consulting with the Department of Public health, Partners defines serious disability related to a fall as any broken bone, head or brain injury or bleeding, lacerations requiring suturing, or other significant impairment to a normal bodily function.

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

ENVIRONMENTAL EVENTS    Click here to read more about Reducing Patient Falls	BWH	MGH	FH	NWH	NSMC	Total Partners
Death or Serious Disability Associated With an Electric Shock	0	0	0	0	0	0
Wrong Gas or Contamination in Patient Gas Line	0	0	0	0	0	0
Death or Serious Disability Associated With a Burn	2	0	2	0	0	4
Death or Serious Disability Associated With a Fall	9	10	3	4	10	36
Death or Serious Disability Associated With the Use of Restraints or Bedrails	0	0	0	0	0	0
Total Environmental Events:	11	10	5	4	10	40

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