Lessons learned from four years of adverse event reporting by acute care hospitals

Massachusetts was an early adopter of Serious Reportable Event (SRE) tracking. Since 2008, hospitals have been required to report events to the Department of Public Health (MDPH) for the purposes of quality improvement and public reporting. Requisite disclosure of events to patients and families, and a prohibition on seeking payment for preventable SREs have increased accountability and maximized transparency. However, when analyzed in isolation, SRE data are insufficiently robust to determine quality of care at the hospital level, hindering meaningful public reporting. Hospitals are required to perform a root cause analysis (RCA) and preventability determination for each SRE. These analyses are not standardized or uniformly evaluated by MDPH, and are not publicly reported. To develop models to maximize impacts of SRE disclosure, we conducted a retrospective analysis of all reported SREs, and examined the correlation between those data and the number and severity of regulatory enforcement actions taken. The number of SREs in Massachusetts acute care hospitals increased from 338 in 2008 to 344 in 2011. Within individual facilities, the number of SREs per 10,000 patient days varies significantly. The number and severity of enforcement actions taken by regulators did not correlate with rates of SREs, and the variability of SRE reporting between hospitals is too large to provide significant conclusions about the relationship of SREs to quality of care. By performing randomized chart audits or requiring the use of global trigger tools, MDPH could ensure that SREs are being consistently reported across facilities, improving data quality. SRE public reporting would then be enhanced by developing a composite quality measure that integrates qualitative regulatory data (such as findings from onsite investigations, RCAs and preventability determinations) with the prevalence of SREs. We anticipate that linking quantitative SRE reports with regulatory data will provide objective standards for determining relative quality of care.