Request for Public Comment: Serious Reportable Events- Pressure Injury

The National Quality Forum (NQF) is seeking public comment as part of the consensus-based process to update the Serious Reportable Events (SRE) List. Specifically, NQF invites the public to review and comment on the proposed 2025 SRE List and event descriptions. Comments are due by July 1.

There are many measures that are available for review & comment, but WOCN wanted to bring to your attention 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.

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 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 presents an updated list that consists of 27 SREs and invites patients, advocates, stakeholders, and the public at large to review and comment on the updated SREs and event descriptions.

For more information, please refer to the Request for Public Comment Document which provides the name and event description for each SRE. Comments can be submitted via this link.