Leveraging serious reportable events to drive regulatory quality improvement initiatives at the Massachusetts department of public health

The Commonwealth of Massachusetts mandates reporting of adverse medical events by health care facilities, authorizing the Department of Public Health (MDPH) to collect and report event data since 2008. We sought to utilize Serious Reportable Event (SRE) prevalence to inform state agency workload and develop decision analyses that enhance triage and compliance actions and streamline process flow. A retrospective review was conducted of all reportable adverse patient care events in Massachusetts acute care hospitals. The eighteen-month review (January 2011–June 2012), encompassed incidents reported by acute care hospitals (n=74), including SREs as defined by the National Quality Forum, and complaints received from consumers. All incidents and investigations were reviewed (n=1,490), including 567 SREs. Three SREs comprised the majority (81%) of events: (1) falls resulting in death or serious disability, 54% (n=304); (2) Stage III or Stage IV pressure ulcers, 16% (n=88); and (3) retained foreign objects, 11% (n=60). MDPH conducted 120 investigations of SREs at acute care hospitals. Significant differences existed in percent of SREs investigated by category. While falls were most prevalent, only 13 (4%) were investigated; one-third of wrong site surgery events were investigated despite accounting for 7% of reported SREs. Though MDPH publicly reports SRE incidence, complex analysis has not previously been performed. Ongoing analysis should focus on tracking SRE trends to direct department activities. There were no consistent criteria for directing investigations, as evidenced by the disparate percentages of investigations between SREs types. Without concrete criteria, MDPH disproportionately investigated rare events, those perceived to be more alarming. MDPH will utilize these findings to develop consistent criteria for initiating onsite investigations, including comprehensive assessment of the quality of improvement activities performed by acute care hospitals. This approach will more significantly leverage the potential improvement impact of conducting on-site investigations that results from a focus on more common events.