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Serious Reportable Adverse Events in Health Care

By Kenneth W. Kizer and Melissa B. Stegun


Health care errors resulting in patient harm are a leading cause of morbidity and mortality in the United States, although there is no national reporting of such occurrences. A number of States require reporting of at least some types of these adverse events; however, it is widely agreed that, even where there is required reporting, such events are grossly underreported, due in part to ambiguity about what is to be reported. In 1999, the Institute of Medicine (IOM) recommended that health care errors and adverse events be reported in a systematic manner. The Federal Government’s Quality Interagency Coordination Committee concurred with the IOM’s recommendation for greater health care error and adverse event reporting, and the National Quality Forum (NQF) was asked to identify a standardized list of preventable, serious adverse events that would facilitate reporting of such occurrences. This article presents the NQF-endorsed consensus list of 27 serious reportable events in health care, along with a discussion of the criteria used in selecting the list and various issues related to implementing reporting of these events. Since the NQF promulgated this list of serious reportable events in 2002, several States and other entities have enacted legislation or taken administrative action to require reporting of these “never events.

Year: 2010
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