Serious Adverse Events
Summary
Hospital leaders work hard to minimize serious adverse events through proven practices and preventive systems. Unfortunately, human error can and does occur. In the rare cases when patients are harmed, hospital leaders must do the right thing for those patients and their families. According to the Health and Human Services Administration, Office of the Inspector General December 2008 report, Adverse Events in Hospitals: Case Study on Incidence Among Medicare Beneficiaries in Two Selected Counties, 15 percent of hospitalized Medicare beneficiaries in two counties experienced an adverse event during their hospital stays.
In July 2007, the AHA Board of Trustees adopted a set of principles to provide guidance to hospital leaders on looking to update their serious events policies. The principles will help leaders evaluate the events to include in the no-charge policy. The AHA asks all member hospitals to review and consider changes. View the February 2008 AHA Quality Advisory.
Linkages to Performance Excellence
Patient Centered —Serious events policies support patients and their families if adverse events occur during the patients hospitalization.
Additional Resources
AHA Quality Advisory: Implementing a No-Charge Policy for Serious, Adverse Events
NQF Patient Safety: Healthcare Acquired Conditions and Serious Reportable Events
CMS Guidelines for Reviewing Case Mix Adverse Event Outcome Reports
CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events
AHRQ Patients reveal adverse events in the hospital that are not documented in the medical records
IHI Develop a Culture of Safety: Create and Adverse Response Team
IHI Develop a Culture of Safety: Simulate Possible Adverse Events
IHI Tool: Communicating after an Adverse Event: Selected Bibliography and Resources
