PATIENT SAFETY RESOURCE CENTER
29 Mistakes That Should Never Happen In A Hospital, But Do
Tracking Serious Reportable Events (SREs) in Massachusetts Hospitals
Massachusetts is well known as home to some of the world's most prestigious hospitals, such as Mass. General Hospital and Brigham and Women’s both recently named among the 20 hospitals listed in the "Best Hospitals Honor Roll" by U.S. News & World Report and Best Hospitals.® However, even here in Massachusetts, serious medical mistakes continue to happen to far too many patients while in the hospital.
As part of a concerted effort to reduce harms to patients, Massachusetts acute care hospitals and ambulatory surgery centers are required by law to track what are called “Serious Reportable Events” and report them to the Department of Public Health.
What are Serious Reportable Events?
A Serious Reportable Event (SRE) as defined by Massachusetts law1 is an event that results in a serious adverse patient outcome that is clearly identifiable and measurable, reasonably preventable, and that meets any other criteria established by the department in regulations. The law also prohibits hospitals from charging for these events or seeking reimbursement for SRE-related services.2
There are 29 SREs (also referred to as "Never Events," as they are events that should never happen in a hospital), developed by the National Quality Forum as part of its patient safety efforts. It describes these Never Events as “a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care.” 3
Massachusetts Serious Reportable Events 2022
A look at SREs over the last 5 years shows that Mass. hospitals continue to make too many avoidable mistakes.
Note: In 2020, 2021 and 2022, nonessential and elective invasive procedures were temporarily reduced due to the pandemic.
Below are the most recent data reported to the Department of Public Health documenting the 29 Serious Reportable Events listed with the total instances reported by the state's acute care hospitals for 2022. For similar information on non-acute care hospitals and ambulatory surgery centers please see the The Massachusetts Health and Human Services website for that publicly available information.
Some of the most common hospital errors in Massachusetts include:
- Falls
- Pressure ulcers
- Medication errors
- Foreign object left behind (surgery)
- Burns
Review the full list of Never Events below.
29 Never Events: Massachusetts Acute Care Hospitals
Surgical or Invasive Procedure Events
- Wrong site surgery of procedure = 40
- Surgery or procedure on wrong patient = 4
- Wrong surgery or procedure = 12
- Unintended retention of a foreign object = 42
- Intraoperative or immediate post-operative death of an ASA Class 1 Patient = 0
Product or Device Events
- Death or serious injury related to contaminated drugs, device or biologics or devices = N/A
- Death or serious injury related to device misuse or malfunction = N/A
- Death or serious injury due to intravascular air embolism = N/A
Patient Protection Events
- Discharge of a patient/resident of any age to other than authorized person = 5
- Death or serious injury associated with patient elopement = 7
- Patient suicide, attempted suicide, or self-harm that results in serious injury = 68
Care Management Events
- Death or serious injury associated with a medication error = 69
- Death or serious injury associated with unsafe blood product administration = 0
- Maternal death or serious injury associated with low-risk pregnancy labor or delivery = 6
- Death or serious injury of neonate = 23
- Death or serious injury associated with a fall = 454
- Stage 3, Stage 4 or unstageable pressure ulcer = 664
- Artificial insemination with wrong donor sperm or egg = 0
- Death or serious injury from irretrievable loss of a specimen = 11
- Death or serious injury from failure to follow up on test result = 14
Environmental Events
- Patient of staff death associated with electric shock = 0
- Any incident in which no gas, wrong gas or contaminated gas delivers to a patient = 6
- Patient of staff death or serious injury associated with a burn = 50
- Death or serious injury associated with restraints or bedrails = 9
Radiology
- Death or serious injury of patient or staff associated with introduction of a metallic object in MRI area = 0
Potential Criminal Events
- Any instance of care provided by someone impersonating a health care provider = 1
- Resident/patient abduction = 0
- Sexual abuse/assault on a patient or staff member = 43
- Death or serious injury patient or staff member as a result of physical assault = 80
Questions about a hospital medical error in MA, NH or RI?
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