In 2006, the National Qualify Forum (NQF) issued a list of 28 Serious Reportable Events (SREs). Fifteen years earlier, I had initiated a major academic wound center and had spent those years trying (and failing) to prevent pressure ulcers in 6 intensive care units including a neurological ICU in which the instability of some patients’ cerebrospinal fluid pressure necessitated “do not turn” orders. Those patients were getting medically unpreventable tissue infarctions that were clearly associated with life-threatening hemodynamic factors.
Pressure ulcers had not yet become one of the most popular and successful reasons to sue major medical centers and doctors after they saved the life of a critically ill patient – but it was happening thanks to the misguided public relations campaign calling them “never events”.
It is important to note that the NQF released their list of SREs ten years before the (then named) National Pressure Ulcer Advisory Panel (NPUAP) changed the staging system. Back in 2006, a Stage 3 pressure ulcer was a potentially bad ulcer. Since 2016, a Stage 3 pressure ulcer is anything that is not partial thickness (e.g. a ruptured blister) but doesn’t expose muscle, tendon or bone. Did the sentence you just read fully sink in?
As you read the NQF announcement below, keep in mind that nowadays, a Stage 3 ulcer/injury is an ulcer that exposes subcutaneous tissue and has any slough or granulation tissue. Let’s all be clear about the fact that nowadays, Stage 3 ulcers are incredibly minor booboos.
Well, back in 2006, I read the NQF list of SREs due to “care management events” and it included horrible events like patient death or serious disability due to the administration of incompatible blood products or medication errors, discharging a mother with the wrong baby, and artificial insemination with the wrong donor sperm or wrong egg. Yes, we could all agree that those were preventable tragedies caused by human error. And then I saw what else was on the list of reportable events which, according to the NQF, were “always the fault of poor care”: “Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.”
In 2006, only the Alliance of Wound Care Stakeholders understood the implications of the NQF’s classification of pressure ulcers. Under the aegis of the Alliance, I went to several NQF meetings in Washington, D.C and even got myself put on one quality committee – which was extremely difficult to do. At first, I had naively hoped to change the NQF statements on pressure ulcers. When it was obvious that no one at the NQF was interested in facts or clinical data, my goal became to understand how healthcare policy could go so wrong. The answer that is complicated, but let’s just say that a lone soldier, even one armed with data, cannot defeat the concerted efforts of misguided organizations that do not understand the (perhaps) unintentional consequences of their health policy “advocacy”.
Twenty years have passed since I first saw the NQF list of SREs which helped to open the door for a flood of egregious lawsuits over medically unpreventable pressure ulcers. Litigation over medically unpreventable pressure ulcers has cost healthcare institutions (and malpractice insurance companies) countless millions of dollars. While the policy change below is subtle, for me it is the last straw.
This is a call to action for medical centers, large healthcare institutions, risk management organizations and insurance companies to band together and fight bad healthcare policy around pressure ulcers. You do not have to give up and just write checks for the medically unpreventable events often incorrectly labeled as pressure “injuries.”
Here’s what I am doing as an army of one: I will continue to provide virtual talks on medically unpreventable pressure ulcers to any of the above organizations – as often as my schedule allows. You can email me at cfife@intellicure.com.
The rest of you – the organizations with resources – you are going to have to stop sitting on the sidelines. You can fight bad policy with data and organized advocacy. If you don’t do this, you can just keep writing checks – BIG checks.
Here’s what I think the most recent announcement by the NQF says about pressure ulcers:
“Starting January 1, 2027, Joint Commission will stop using its own standalone Sentinel Event (SE) list and will instead use the NQF Serious Reportable Events (SRE) list as the Sentinel Event list for accreditation purposes.”
All pressure injuries except stage 1 and 2, in all care settings are now unequivocally “sentinel-level” events if they result in “serious harm” Facility-acquired Stage 3, Stage 4, unstageable, and deep tissue pressure injuries with serious harm are explicitly part of the Sentinel Event universe.
Reporting is still “voluntary”(-ish). Care settings accredited by the Joint Commission are not required to report events to Joint Commission although surveyors will expect your internal definitions to align with the new SRE-based list.
“Joint Commission will maintain its expectation that all accredited healthcare organizations identify sentinel events, examine the root causes and contributing factors, and make improvements to mitigate the risk of reoccurrence. In January 2027, Joint Commission will revise both the domestic and international Sentinel Event Chapter and adopt the 28 SREs, the updated SRE Inclusion Criteria, and the SRE Clinical Application Guidance…”
Since “Serious harm” can only be determined retrospectively – I do not understand who is supposed to report what to whom, but serious harm it is defined as:
- Physical Harm (death, permanent or severe temporary harm)
- Emotional or Psychological Harm (e.g., severe, long-term psychological distress related to disfigurement; trauma requiring behavioral health interventions, etc.)
- Major Interventions (defined as a procedure involving significant risk, anesthesia, or substantial bodily invasion) Be aware that NPWT and debridement might be considered to be “substantial bodily invasion.”
- Impairment of Activities of Daily Living (ADLs)
Remember that any “pressure” ulcer with granulation tissue or slough is automatically a Stage 3 and thus might represent an SRE, if in the “retrospectoscope” it could be considered to have been preventable and it leads to any of the four things listed above.
Additional Materials:
- Updating the Serious Reportable Events (SRE) List | NQF
- Frequently Asked Questions: Alignment of Patient Safety Event Reporting Update
The post The Last Straw: Healthcare Facilities, Risk Management Organizations & Insurance Companies Need to Revolt Over US Pressure Injury Policy appeared first on Caroline Fife M.D..