APPENDIX VI: The National Quality Forum’s List of Serious Reportable Events, 2011

Surgical or invasive procedure events (n = 5)

• Surgery or other invasive procedure performed on the wrong site

• Surgery or other invasive procedure performed on the wrong patient

• Wrong surgical or other invasive procedure performed on a patient

• Unintended retention of a foreign object in a patient after surgery or other invasive procedure

• Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient

Product or device events (n = 3)

• Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting

• Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended

• Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting

Patient protection events (n = 3)

• Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person

• Patient death or serious injury associated with patient elopement (disappearance)

• Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

Care management events (n = 9)

• 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)

• Patient death or serious injury associated with unsafe administration of blood products

• Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting

• Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy (new in 2011)

• Patient death or serious injury associated with a fall while being cared for in a healthcare setting

• Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting

• Artificial insemination with the wrong donor sperm or wrong egg

• Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen (new in 2011)

• Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results (new in 2011)

Environmental events (n = 4)

• Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting

• Any incident in which systems designated for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas, or are contaminated by toxic substances

• 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

• Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

Radiologic events (n = 1)

• Death or serious injury ...