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.

To provide context for understanding the frequency of these events, we show some key numbers for each hospital. This "Hospital Information" table includes the number of beds, the number of patients discharged overall and for surgical conditions, and the volume of outpatient surgical procedures performed in the same time period as these serious reportable events. Although we aim for zero events of this type, we hope this information helps the reader understand that these are occurrences are very infrequent.

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

» Show Partners HealthCare Scores Table
Hospital Information for 2008	BWH	MGH	FH	NWH	NSMC	Total
Licensed Beds	777	907	153	246	415	2,498
Total Hospital Discharges	53,116	50,606	8,286	18,715	21,639	152,363
Surgical Hospital Discharges	18,722	20,048	2,382	3,529	4,542	49,223
Ambulatory Surgical Procedures	11,775	17,905	8,142	11,198	12,336	61,356
SURGICAL EVENTS    Click here to read more about Eliminating Surgical Serious Reportable Events	BWH	MGH	FH	NWH	NSMC	Total
Wrong Body Part	1	3	0	0	0	4
Wrong Patient	0	0	0	0	0	0
Wrong Procedure	0	1	0	0	0	1
Retention of a Foreign Object	2	1	0	1	0	4
Death of ASA Class 1 Patient	0	0	0	0	0	0
PRODUCT OR DEVICE EVENTS	BWH	MGH	FH	NWH	NSMC	Total
Use of Contaminated Drugs, Biologics or Device	0	0	0	0	0	0
Misuse/Malfunction of a Device	0	1	0	0	0	1
Air Embolism	1	0	0	0	0	1
PATIENT PROTECTION EVENTS	BWH	MGH	FH	NWH	NSMC	Total
Infant Discharged to the Wrong Person	0	0	0	0	0	0
Patient Elopement	0	0	0	0	0	0
Patient Suicide	0	0	0	0	0	0
CARE MANAGEMENT EVENTS	BWH	MGH	FH	NWH	NSMC	Total
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
ENVIRONMENTAL EVENTS    Click here to read more about Reducing Patient Falls	BWH	MGH	FH	NWH	NSMC	Total
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
CRIMINAL EVENTS	BWH	MGH	FH	NWH	NSMC	Total
Care Ordered by Someone Impersonating an MD, RN, or Other Provider	0	0	0	0	0	0
Abduction of a Patient	0	0	0	0	0	0
Sexual Assault of a Patient	0	0	0	0	0	0
Death or Injury of a Patient or Staff From Physical Assault	0	0	0	0	0	0
Total For All Events:	18	16	5	5	10	54

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