February 20, 2004 |
2004-R-0240 | |
NATIONAL QUALITY FORUM AND REPORTABLE EVENTS IN HEALTHCARE | ||
| ||
By: John Kasprak, Senior Attorney | ||
You asked for information on the “National Quality Forum” and its list of “serious reportable events” in health care.
BACKGROUND
The National Quality Forum (NQF; formally incorporated as the National Forum for Health Care Quality Measurement and Reporting) is a not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was established as a pubic-private partnership and has participation from all parts of the health care system, including national, state, regional and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement.
Mission and Goals
NQF’s mission is “to improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient” (see www. qualityforum. org).
Specific goals of NQF are to:
1. Promote collaborative efforts to improve the quality of the nation’s healthcare through performance measurement and public reporting;
2. Develop a national strategy for measuring and reporting healthcare quality;
3. standardize healthcare performance measures so that comparable data is available across the country (i. e. , establish national voluntary consensus standards);
4. Promote consumer understanding and use of healthcare performance measures and other quality information; and
5. Promote and encourage the enhancement of system capacity to evaluate and report on healthcare quality.
Board of Directors
A 23-member Board of Directors representing healthcare consumers, purchasers, providers, health plans, and experts in health services research governs NQF. The board includes representatives from two federal agencies (the Center for Medicaid and Medicare Services and the Agency for Health Care research and Quality).
Funding
Membership dues are a key source of NQF funding. The Forum also receives significant public and private funding, including foundation and corporate grants. NQF received a founding grant of $ 2. 5 million from the Robert Wood Johnson Foundation. (A list of other founding contributors can be found on the website noted above. )
NQF’S LIST OF SERIOUS REPORTABLE EVENTS IN HEALTHCARE
In March 2002, NQF released a report, Serious Reportable Events in Healthcare: A National Quality Forum Consensus Report, designed to form the basis for a national, state-based adverse events reporting system. The report identifies 27 adverse events in six major categories: (1) surgical events, (2) product or device events, (3) patient protection events, (4) care management events, (5) environmental events, and (6) criminal events.
Table 1 presents the list of serious reportable events.
TABLE 1: NQF’s List of Serious Reportable Events
Event |
Additional Specifications |
1. SURGICAL EVENTS A. Surgery performed on the wrong body part |
Defined as any surgery performed on a body part that is not consistent with the documented informed consent for that patient. Excludes emergent situations that arise in the course of surgery and/or whose exigency precludes obtaining informed consent. Surgery includes endoscopies and other invasive procedures. |
B. Surgery performed on the wrong patient |
Defined as any surgery on a patient that is not consistent with the documented informed consent for that patient. Surgery includes endoscopies and other invasive procedures. |
C. Wrong surgical procedure performed on a patient |
Defined as any procedure performed on a patient that is not consistent with the documented informed consent for that patient. Excludes emergent situations that arise in the course of surgery and/or whose exigency precludes obtaining informed consent. Surgery includes endoscopies and other invasive procedures. |
D. Retention of a foreign object in a patient after surgery or other procedure |
Excludes objects intentional implanted as part of a planned intervention and objects present prior to surgery that were intentionally retained. |
E. Intraoperative or immediately post-operative death in an American Society of Anesthesiologists (ASA) Class I patient |
Includes all ASA Class I patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out. “Immediately post-operative” means within 24 hours after induction of anesthesia (if surgery not completed), surgery, or other invasive procedure was completed. |
2. PRODUCT OR DEVICE EVENTS A. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility |
Includes generally detectable contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product. |
B. Patient death or serious disability associated with the use of function of a device in patient care in which the device is used or functions other than as intended |
Includes, but is not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators. |
C. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility |
Excludes deaths associated with neurosurgical procedures know to present a high risk of intravascular air embolism. |
-Continued-
Event |
Additional Specifictions |
3. PATIENT PROTECTION EVENTS A. Infant discharged to the wrong person |
|
B. Patient death or serious disability associated with patient elopement (disappearance) for more than four hours |
Excludes events involving competent adults. |
C. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility |
Defined as events that result from patient actions after admission to a healthcare facility. Excludes deaths resulting from self-inflicted injuries that were the reason for admission to the healthcare facility. |
4. CARE MANAGEMENT EVENTS A. Patient death or serious disability 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) |
Excludes reasonable differences in clinical judgment on drug selection and dose. |
B. Patient death or serious disability associated with a hemolytic reaction due to the administration of incompatible blood or blood products |
|
C. Maternal death or serious disability with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility |
Includes events that occur within 42 days after delivery. Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy. |
D. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility |
|
E. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinimia in neonates |
Hyperbilirubinimia is defines a bilirubin levels >30mg/dl. “Neonates” refers to the first 28 days of life. |
F. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility |
Exclude progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission. |
G. Patient death or serious disability due to spinal manipulative therapy |
|
5. ENVIRONMENTAL EVENTS A. Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility |
Excludes events involving planned treatments such as electric countershock. |
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 disability associated with a burn incurred from any source while being cared for in a healthcare facility |
|
D. Patient death associated with a fall while being cared for in a healthcare facility |
|
E. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility |
-Continued-
Event |
Additional Specifications |
6. CRIMINAL EVENTS A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider |
|
B. Abduction of a patient of any age |
|
C. Sexual assault on a patient within or on the grounds of a healthcare facility |
|
D. Death or significant 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 facility |
Source: National Quality Forum
JK: ts