NQF Releases Update to Never Events
The recent headline of the NICU nurse in Seattle, who committed suicide after overdosing a baby, reveals some of the anguish healthcare professionals experience when making a severe medical error. Particularly shocking medical errors are termed Never Events and include adverse (sentinel) events which are clearly identifiable and measurable, and serious (resulting in death or significant disability) events, usually preventable (AHRQ, 2006).
The National Quality Forum (NQF) is a nonprofit organization that strives to improve the quality of American healthcare by establishing goals for performance improvement, endorsing national standards for measuring and reporting on performance, and promoting the attainment of national safety goals through education. The NQF Board recently approved a list of 29 serious reportable events (SREs) in healthcare in their 2011 Consensus Report. Of these 29 events, 25 were updated from 2006, and 4 new events were added to the list (NFQ, 2011). This newly expanded list of serious reportable events (never events) provides healthcare professionals with an opportunity to improve patient safety.
In addition to adding a category of events, the NQF also expanded the list of specific practice settings in which SREs apply. The updated list now includes hospitals, outpatient or office-based surgery centers, skilled nursing facilities, and ambulatory practice settings (specifically office-based practices). The NQF also enlarged the number of categories of events from six to seven. The seven current categories include: Surgical, Product or Device, Patient Protection, Care Management, Environmental, Radiologic and Criminal (NQF, 2011).
According to the NQF (2011), over 50% of states currently use the NQF-endorsed list of SREs in their public reporting programs. In an effort to keep your practice up to date and focused on safety initiatives, RN.com recently released a new course entitled: Never Events: Nurse’s Key Role. This interactive, one contact hour continuing education course for healthcare professionals explains the evolution of Never Events and identifies nurses’ key role in preventing Never Events and assuring patient safety. This course has been updated to reflect the new changes to the NQFs list of SREs.
Agency for Health Care Research and Quality [AHRQ]. (2011). Never Events. Retrieved from: http://www.qualityforum.org/About_NQF/About_NQF.aspx
National Quality Forum [NQF]. (2011). About NQF. Retrieved from: http://www.qualityforum.org/About_NQF/About_NQF.aspx
National Quality Forum [NQF]. (2011). NQF Releases Updated Serious Reportable Events. News and Resources. Retrieved from: http://www.qualityforum.org/Press_Releases.aspx