that should never happen in any clinical care setting,
but unfortunately do and should be publicly reported when they occur" - (NQF, 2002)
The National Quality Forum (NQF) has made a significant contribution to patient safety. Through a consensus building process involving a broad spectrum of healthcare stakeholders, the NQF has created a standardized list of serious reportable events (SREs). The list contains 28 preventable adverse events that can be used to form a state-based or national reporting system. In fact, the U.S. government and many states are adopting some or all of these events as mandatory reportable events.
National Quality Forum
A. Invasive procedure on the WRONG SITE
|Product or Device Event|
death or serious injury associated with the use of contaminated drugs,
devices or biologics provided by the healthcare setting
B. Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
C. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare setting
|Patient Protection Events|
A. Patient of any age discharged to an unauthorized person
|Care Management Events|
death or serious injury associated with a medication error (e.g. wrong drug, wrong dose, wrong patient, wrong time, wrong
rate, wrong preparation or wrong route of administration)
death or serious injury associated with an electric shock while being
cared for in a healthcare setting
B. 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
C. Patient death or serious injury associated with a burn incurred from any source while being cared for in a healthcare setting
D. Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare setting
|Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area.|
instance of care ordered or provided by someone impersonating a physician,
nurse, pharmacist, or other licensed healthcare provider
"Never events" are without question the most catastrophic of all healthcare safety failures. They often receive extraordinary attention and rightfully so. Acknowledging the seriousness of the error and presenting a meaningful plan to avoid replication is often the most effective way to re-establish public trust in the healthcare system.
The occurrence of a "never event" does not indicate a lack of commitment to patient safety. The true measure of an organization's safety commitment is its response to each "near-miss." Every near-miss offers your organization the opportunity to learn, improve and prevent potential "never events." Protect yourself, your patients and your organization by completing an "incident report" when the slightest harm occurs or when any safety risk is identified.
Click here to visit the National Quality Forum web site.
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