Joint Commission and the National Quality Forum (NQF) recently announced they are aligning the Joint Commission’s Sentinel Events (SE) List and NQF’s recently updated Serious Reportable Events (SRE) List, streamlining safety event reporting and eliminating the need to maintain separate safety measurement frameworks. The report, Aligning Patient Safety Event Reporting, details the updates and includes specific application guidance to enable a standardized implementation. Click here to review and download.
Joint Commission will adopt the updated SRE List as part of the SE List effective January 1, 2027, across all accredited organizations, domestic and international, allowing time for healthcare organizations to make the required changes, and will provide technical support to accredited organizations during the transition.
We are urging WOC nurses to pay particular attention to SRE 21: Patient Harm Associated with a Stage 3 Pressure Injury, Stage 4 Pressure Injury, Unstageable Pressure Injury, or Deep Tissue Pressure Injury Acquired After Admission, found on pages 111-114.
Joint Commission and NQF will host a patient safety capstone webinar that will cover updates to the SREs on March 3, 2026, 1:00 – 2:15 PM ET. Click here to register.
Background:
NQF first published the SRE List in 2002, and last updated it in 2011. For each iteration of the SRE list, NQF convened experts to identify a consensus-based subset of patient safety incidents that are not only largely preventable but also so serious that they should never occur in healthcare settings. Many states and healthcare organizations use the SRE List today for both mandatory and voluntary SRE reporting.
In 2024, NQF launched an initiative that focused on developing a unified, consensus-based, updated SRE List that reflects changes to how and where care is delivered in today’s environment. This update consists of three major components: (1) refinement of the inclusion criteria, (2) expansion of applicable healthcare settings, and (3) revision of the events and the accompanying application guidance. Throughout the initiative, NQF convened several technical expert panels or groups, engaging over 70 experts. In June 2024, NQF held a public comment period and conducted a call for candidate events as part of the consensus-based process for updating the SRE List. Specifically, NQF encouraged the submission of candidate patient safety events that align with the updated SRE Inclusion Criteria.
NQF received a total of 50 event submissions, which were reviewed and consolidated into 37 candidate events. In July 2024, NQF conducted a second public comment period to garner feedback on the 37 candidate events being considered for inclusion on the updated SRE List, and the 29 existing events from the Serious Reportable Events In Healthcare – 2011 Update: A Consensus Report, which were also being reviewed.
NQF presented an updated list that consists of 27 SREs and invited patients, advocates, stakeholders, and the public at large to review and comment on the updated SREs and event descriptions.
While there were many measures that were available for review and comment, the WOCN Society asked the WOC nursing community to pay particular attention to the following measure dealing with pressure injury:
SRE 15*. Patient Harm Associated With a Stage 3 Pressure Injury, Stage 4 Pressure Injury, or Deep Tissue Injury Acquired After Admission This event captures patient harm associated with the development of Stage 3 or Stage 4 pressure or deep tissue injuries after the initiation of a patient encounter with a healthcare setting. This event includes recognition and documentation of newly acquired Stage 3 and Stage 4 pressure injuries or deep tissue injuries that are not present on admission. Since many pre-admission circumstances (e.g., immobility after a fall) may contribute to the development of pressure or deep tissue injuries, this event focuses on occurrences that are noted to be likely avoidable and require major intervention. This event applies to all healthcare settings (as listed in Appendix A) except virtual and hospice care. Note: This event was on the 2011 SRE List and modified to narrow the scope to only Stage 3 and 4 pressure or deep tissue injures acquired after admission that are likely avoidable and require major intervention. Additionally, the event terminology was updated from pressure ulcer to pressure injury.
*SRE 15 has been replaced by SRE 21 in the newly published 2025 Updates to Sentinel Events and Serious Reportable Events.