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DPH Releases Latest Serious Medical Errors Report

DPH Releases Latest Serious Medical Errors Report

August 19, 2014

DPH Slide - Serious Reportable Events in Massachusetts 2013

The MA Department of Public Health last week released its most recent set of data on Serious Reportable Events (sometimes called “never events”).

The list of 29 Serious Reportable Events (SREs) is developed by the National Quality Forum (NQF) and periodically changed/updated.  The list includes items such as wrong patient surgery and wrong site surgery, serious medication errors, falls, and pressure ulcers, and more. In 2012, NQF changed the definitions of some of the SREs and also added some new SREs, which may have resulted in increased numbers reported for those areas. For example, the definitions of serious medication errors and falls were changed to include those that resulted in serious injury or death while previously the definition had been disability or death.

In 2013, DPH introduced a new electronic reporting system in order to facilitate the reporting of SREs, which also may have led to an increase in numbers. The data that DPH released this week covers the years 2011, 2012, and 2013 and includes numbers for how many of each type of SRE occurred in each hospital in each of those years.

You can find the reports for acute care and non-acute care hospitals on the DPH website. Each year, the greatest numbers of reported events were serious falls and pressure ulcers. At last week’s Public Health Council meeting, DPH staff gave an overview of the reports and also discussed many of their efforts to streamline the reporting process and more closely analyze the data (also see this Boston Globe article about the reports).

  -Deb Wachenheim