Serious Reportable Events

The National Quality Forum has identified a list of 29 Serious Reportable Events, or "Never Events", which are a set of serious, preventable, harmful clinical events that should never, EVER happen in any medical institution.


Below is our most current data for 2013 and 2012.


Metric 2013
Goal Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TOTAL
1. SURGICAL OR INVASIVE PROCEDURE EVENTS  
1A. Surgery or other invasive procedure performed on the wrong site 0 0 0 0 0                 0
1B. Surgery or other invasive procedure performed on the wrong patient 0 0 0 0 0                 0
1C. Wrong surgical or other invasive procedure performed on a patient 0 0 0 0 0                 0
1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure 0 0 0 0 0                 0
1E. Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient 0 0 0 0 0                 0
2. PRODUCT OR DEVICE EVENTS  
2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting 0 0 0 0 0                 0
2B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended 0 0 0 0 0                 0
2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting 0 0 0 0 0                 0
3. PATIENT PROTECTION EVENTS  
3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 0 0 0 0 0                 0
3B. Patient death or serious injury associated with patient elopement (disappearance) 0 0 0 0 0                 0
3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting 0 0 0 0 0                 0
4. CARE MANAGEMENT EVENTS  
4A. Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) 0 0 0 0 0                 0
4B. Patient death or serious injury associated with unsafe administration of blood products 0 0 0 0 0                 0
4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting 0 0 0 0 0                 0
4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy 0 0 0 0 0                 0
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting 0 0 0 0 0                 0
4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting 0 0 0 1 0                 1
4G. Artificial insemination with the wrong donor sperm or wrong egg 0 0 0 0 0                 0
4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen 0 0 0 0 0                 0
4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 0 0 0 0 0                 0
5. ENVIRONMENTAL EVENTS  
5A. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting 0 0 0 0 0                 0
5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances 0 0 0 0 0                 0
5C. Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting 0 0 0 0 0                 0
5D. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting 0 0 0 0 0                 0
6. RADIOLOGIC EVENTS  
6A. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area 0 0 0 0 0                 0
7. POTENTIAL CRIMINAL EVENTS  
7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 0 0 0 0 0                 0
7B. Abduction of a patient/resident of any age 0 0 0 0 0                 0
7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 0 0 0 0 0                 0
7D. Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting 0 0 0 0 0                 0

Metric 2012
Goal Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TOTAL
1. SURGICAL OR INVASIVE PROCEDURE EVENTS  
1A. Surgery or other invasive procedure performed on the wrong site 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1B. Surgery or other invasive procedure performed on the wrong patient 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1C. Wrong surgical or other invasive procedure performed on a patient 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1E. Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2. PRODUCT OR DEVICE EVENTS  
2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3. PATIENT PROTECTION EVENTS  
3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3B. Patient death or serious injury associated with patient elopement (disappearance) 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4. CARE MANAGEMENT EVENTS  
4A. Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4B. Patient death or serious injury associated with unsafe administration of blood products 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4G. Artificial insemination with the wrong donor sperm or wrong egg 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5. ENVIRONMENTAL EVENTS  
5A. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5C. Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5D. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6. RADIOLOGIC EVENTS  
6A. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7. POTENTIAL CRIMINAL EVENTS  
7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7B. Abduction of a patient/resident of any age 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7D. Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting 0 0 0 0 0 0 0 0 0 0 0 0 0 0