Patient Safety & Clinical Quality

Navigating Neverland: Prioritizing the Quality of Patient Safety

What does your facility do with its Event and Incident data?

Navigating Neverland patient safety blog header


Since 1999, when the Institute of Medicine (IOM) published, “To Err is Human: Building a Safer Health System” (which you can download for free from, there has been an urgent call to action for health care facilities to prioritize the quality of patient safety and care.

Medical Error is the Third Leading Cause of Death

In a recent news release sent out by Johns Hopkins professor of surgery, Martin Makary, it is estimated that medical error is the cause of more than 250,000 patient deaths or 9.5% of ALL deaths each year in this country.

This figure was based on Johns Hopkins patient safety experts who analyzed national medical death data over a period of eight years (4).

This data puts patient death due to medical error as the third leading cause of death in the United States. However correct these numbers may or may not be, this still signifies that even nearly 20 years later, patient safety and reduction of medical errors are NOT being taken seriously in our hospitals.

Makary states, “Incidence rates for deaths directly attributable to medical care gone medical error deaths and patient safetyawry haven’t been recognized in any standardized method for collecting national statistics (4).” 

This indicates that national data on adverse events/significant patient safety events regarding morbidity/mortality is highly inaccurate and suggests that the occurrences are significantly underreported.

Isn’t it time that we do something about this? 

What does your facility do with its Event and Incident data? Is the data at least somewhat transparent throughout your organization and are you a part of the action being taken to correct issues?

In 2002, the National Quality Forum (NQF) two signs pointing opposite directions that both read: Neversponsored by AHRQ, developed a list of “Serious Reportable Events (SREs).”

SREs, also known as “Never Events” are defined as “preventable serious events that are reportable and include specific criteria.” Since 2002, multiple state and other agencies have instituted legislation to require reporting of these events (1).


Take a moment to refresh yourself on which events qualify as “Serious Reportable Events.”

List of the “SRE”s from the NQF 2006 Update:

NQF list of serious reportable events

The Swiss Cheese Effect

WHO swiss cheese effect

According to AHRQ, largely, patient safety failures are preventable and not usually related to individual negligence or professional misconduct but rather the result of multiple small failures lining up: the Swiss cheese effect.

AHRQ contends that identifying the points in the process where failures occur and then improving the process reduces the potential for patient harm.

In order to assist in this effort, the list of “Serious Reportable Events” (SREs) was developed so that process failures could be identified and remedied and to create public accountability for adverse events incurred in the delivery of health care (1).

Many of the events listed above are conditions included in the Joint Commission core measures and in the CMS Hospital Acquired Condition Reduction Program (1), which demonstrates these are indeed national issues and action needs to immediately be taken to improve the numbers.

Keep in mind that even the Joint Commission only has a voluntary reporting system for what it deems as Sentinel Events (SE), so the data released on SEs is highly inaccurate.


Mandatory Reporting

The Institute of Medicine (IOM) has recommended mandatory reporting of these events nationally but currently there is not a national mandatory reporting system in effect or even seriously being considered. However, as of 2009, 27 states have instituted either mandatory or voluntary reporting systems for SREs (3).NASHP Map reporting system for serious reportable events

Is your state required to report “Serious Reportable Events,” and if so, are you familiar with the data? Is it published annually to all healthcare organizations, and if so, is it aggregated in such a way that it increases concern and calls you to action? 


Questions to ponder

Look at your own facility:

  • Are you aware of any medical events or incidents that have recently occurred?

  • What about the details of the event?

  • Is transparency recognized and embraced so even your front-line staff is aware of any near-misses?

  • Does Quality & Risk determine the root cause and present their determinations/report to all staff as a learning exercise?

  • Do processes improve and change as a result?

The AHRQ believes that healthcare organizations can improve if they use data to investigate and assess the root cause and then aggregate the information and disseminate it (1) throughout the entire facility.


Call to Action

If the current state of our healthcare system,
which is killing approximately a quarter of a million patients each year due to medical errors
, doesn’t call you to act, what will?

These events occur on a daily basis across our country and it really does seem that no one is paying enough attention to take the time to make sure that the events will never, ever occur again within their facility.

About all that happens is that an incident form is filled out and sent off and people continue to go about their day.

In continuing that kind of behavior, graphic that reads: time for actionthe situation will never improve and, honestly, there is no point in collecting data if you’re not going to do something with it.

Right now, by doing nothing, you’re part of the problem, not part of the solution.



Safety Reporting & Improvement on the Readiness Rounds platform is a significant step up in providing easy access throughout your organization for the processing, analysis, and actioning of events as they occur.

Safety Reporting & Improvement comes with fully-customizable templates and "degree of harm" assessments. In addition, the platform has the ability to add unlimited additional event-type templates.

If you'd like a free demo, we'd be happy to show you around.


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2)–2006_Update.aspx  (download publication)

3) Patient Safety Map & Toolkit. (2009, August 31). Retrieved from National Academy for State Health Policy:

4) Study Suggests Medical Error Now Third Leading Cause of Death in the U.S. (2016, May 3). Retrieved from Johns Hopkins Medicine:

 Previous Post: Sentinel Events & Patient Safety: The Disturbing Data, Part 2

sentinel events patient safety blog link

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