A new definition

A proposed change that would drop the word “never” from the National Quality Forum's definition of serious reportable events has sparked debate among providers and some advocacy groups.

The term “serious reportable events”—more widely known to the public as “never events”—refers to a list of 28 serious patient-care incidents, including surgery performed on the wrong patient or a patient death from a medication error. In early January, the NQF's 20-member Serious Reportable Events Steering Committee reviewed the existing definition, which identifies serious reportable events as “preventable, serious and unambiguous adverse events that should never happen.”

The newly proposed definition would remove the word “never” and replace it with “not,” as in “should not occur,” said Janet Corrigan, president and CEO of the NQF.

It's a small change, but a significant one, said Leah Binder, a member of the steering committee and CEO of the Leapfrog Group, a healthcare quality organization formed by large employers. Binder, who voted against the revision, said the new definition signals that providers are downgrading the significance of such errors.

“The word ‘never' captures that commitment to do everything humanly possible to avoid these events,” Binder said. “It has resonance and removing it as though it were an editorial decision sends a powerful message.”

But other members of the committee argue the proposed change does not downplay the significance of those “never events,” but will instead broaden the scope of the definition to include a greater number of adverse events in a range of care settings.

Specifically, Corrigan said, the new goal of the committee is to expand the list to encompass events such as patient falls, where there are preventive measures in place, but clinicians cannot always keep them from happening. In addition, they want to encourage more reporting from nursing homes, ambulatory surgery centers and outpatient clinics.

“Changing the definition is a necessary part of adding more events to the list,” said Sally Tyler, one of the steering committee co-chairs and a senior health policy analyst for the American Federation of State, County and Municipal Employees, a union of public employees and healthcare workers.

“Surgery on the wrong limb is still something that should never occur, of course, but we think the change will make the definition more inclusive and encourage more reporting,” Tyler said.

The change is also important because the term “never” often conflicts with clinical realities, said Gregg Meyer, who co-chairs the steering committee with Tyler and is also senior vice president for quality and safety at 907-bed Massachusetts General Hospital in Boston.

During the H1N1 pandemic, several patients with severely compromised heart and lung function received extracorporeal membrane oxygenation, an intensive cardiac and respiratory treatment that required them to be completely immobilized, Meyer said. As a result, some patients developed Stage III pressure ulcers—one of the NQF's 28 serious adverse events.

“Obviously we all agree that patients should not get Stage III pressure ulcers, but this was a special case,” Meyer said. “We wanted to allow for those instances and we wanted to look beyond the original small list of events, and you can't do that when you stick with ‘never.' ”

The committee is accepting comments on the proposed definition until Feb. 2.

If approved, the new wording may prompt more open reporting, said Kathy Dorich, manager of quality and patient safety at 290-bed Advocate South Suburban Hospital in Hazel Crest, Ill.

“There are some events that are never truly preventable, and this may be a step toward transparency,” Dorich said. “There is still some hesitancy among providers, and we need to change that culture.”

Maureen McKinney is a freelance healthcare writer based in Chicago.

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