Medical Errors, Adverse Events and the National Quality Forum

Serious Reportable Events, Never Events and Adverse Events

A medical insurance claim form.
A medical insurance claim form. Peter Dazeley/Getty Images

First used in 2001, the term never events was applied by the National Quality Forum (NQF) to describe mistakes that should never happen in hospitals. Those violations, also called adverse events, were considered so heinous that they should never take place. That list was updated and expanded in 2006.

In 2011, the medical errors list was further updated and expanded to cover 29 events that fall under seven categories.

During that time, the name never events was also changed to serious reportable events (SRE). Further, the list of locations and facilities was expanded to cover out-patient or office-based surgery centers, skilled nursing facilities and ambulatory practice settings (doctors' offices) in addition to hospitals.

What is the National Quality Forum? The NQF is a coalition of public and private healthcare sector leaders who are focused on ensuring healthcare quality and patient protection by providing measurement vehicles and public reporting.

Why is such a list important? It is actually used to command quality from those who deliver healthcare to Americans. For example, Medicare, Medicaid and some private insurers will not reimburse doctors or facilities when one of their patients is a victim of an SRE. The Joint Commission, which is the accreditation body used by most U.S. hospitals, takes reported SREs into account when reviewing the facility for its updated accreditation.

According to the NQF, as of 2011, about half of all states use the SRE list to assess the quality of their healthcare facilities, too.

Patients benefit in two important ways from the Serious Reportable Events list:

  1. We know what medical mistakes and events we need to try to prevent on our own. The list of SREs is a list of unacceptable outcomes, one that helps us determine what preventive measures we need to take and one that outlines what might result in a lawsuit.
  1. When payers refuse to pay providers for making these mistakes, it puts the pressure on providers to figure out how to avoid adverse events. That can contribute to a safer environment for patients.

But there are also problems with the Serious Reportable Events list:

  1. As in the past, the current list of never events or serious reportable events does not mention some medical errors that are just as devastating to patients, such as:
  2. If a provider knows he or she won't be reimbursed because a never event or serious reportable event took place, they may try to cover up an event that does occur. Patients report having suffered these events, only to learn later that their records have been amended, actual events have been removed from the records and that their only recourse is to deal with the facility's risk management department. At that point they have no choice but to contact a lawyer for help.

    Categories of Serious Reportable Events

    Here are the categories under which the NQF serious reportable events fall:

    • Surgical or invasive procedure events
    • Product or device events
    • Patient protection events
    • Care management events
    • Environmental events
    • Radiologic events
    • Potential criminal events

    Learn more about each of the National Quality Forum's 29 SREs.

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