Serious Reportable Events Report On-Line

The MA Department of Public Health has issued its most recent reports on the occurrence of Serious Reportable Events (SREs) in Massachusetts hospitals.

Health Care For All and the Consumer Health Quality Council advocated for the law requiring public reports on SREs and Healthcare-Associated Infections (due to come out soon). We commend DPH, and particularly the dedicated staff at the Bureau of Health Care Safety and Quality, for its hard work compiling the data and publishing the reports, especially considering the budget cuts the department has endured the past few years.

You can find reports for acute and non-acute hospitals, for all of 2010 and the first half of 2011, on the DPH website). The reports list the numbers and types of SREs that occurred at every hospital. I also encourage you to view, on the same page, the Public Health Council presentation explaining the reports, SREs, and work related to reducing SREs.

In sum, there were 369 SREs in acute care hospitals in 2010 and 159 during the first half of 2011. About half of the SREs were serious falls which resulted in disability or death.  The next largest category of SREs was advanced pressure ulcers. At the non-acute hospital, there were 143 SREs reported in 2010 and 58 the first half of 2011. Again, about half were falls. As you can see in the presentation materials, there is a lot of work going on across the state to reduce falls and pressure ulcers.

Madeleine Biondolillo, the director of the Bureau of Health Care Safety and Quality, did say that there are some concerns with the validity of some data and the Bureau will work to make sure the data are valid. Serious medication errors was given as an example of an area in which the validity is uncertain since so few of them are reported as SREs. She said that the bureau will be investigating “near misses” as well to help further their understanding of hospital safety.

Public reports serve multiple goals. They provide the public with information about the quality of care provided at hospitals. They give health care providers a better sense of how they are doing and where they need to improve. And they can direct policymakers and advocates to areas that may need more attention. However, the information is also complex and it is not always possible to look at a table and draw immediate conclusions about quality and safety. While the goal should be zero SREs, we also want to make sure hospitals are reporting those SREs that do occur so that they can learn from them, and learn from one another, in order to prevent them from happening in the future.  And we want to encourage hospitals to be up-front with their patients and family members when SREs occur.  So look at the reports and ask your hospital for more information on what they are doing to prevent SREs. Ideally, public reports on serious reportable events, infections, and more lead to conversations within the hospitals, among hospitals, and between consumers and hospitals so that ultimately we can reach the goal of zero.
-Deborah Wachenheim

About HCFA

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