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Questions and Answers
All serious reportable events (SREs) are classified as preventable.
False
Severe harm and death are included in the count of SREs.
True
Behaviour events can include actual self-harm and suicide attempts.
True
SREs can only include physical contact events that cause harm to patients.
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The total number of SREs includes never events only.
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Important events for public credibility are part of the criteria for SRE classification.
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Only healthcare professionals are concerned with serious reportable events.
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Blood and plasma product administration can lead to SREs due to incorrect patient identification.
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A patient can be discharged to an unauthorised person if the patient is unable to make decisions.
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Radiation overdose can occur due to either incorrect treatment or environmental hazards.
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Unexpected deaths unrelated to a patient’s natural course of illness are considered patient safety events.
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Administration of medication to the correct patient is always considered safe.
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User errors involving medical devices can result from utilizing equipment on the incorrect patient.
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A maternal death occurring during childbirth is classified as a perinatal event.
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Confidentiality breaches regarding personal information are deemed less critical than unauthorized access of medical records.
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Incorrect inhalation anaesthetic agents during surgery are a significant safety concern.
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A perineal tear during delivery is not classified as an injury to the body part.
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Severe harm resulting from the administration of incorrect gas mixtures is categorized as a patient safety event.
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Study Notes
Serious Reportable Events (SREs)
- Events in healthcare with significant consequences warranting additional resources for response.
- Includes “Never Events” - unambiguous, serious, and potentially preventable.
- SREs are categorized based on event type, not exclusive criteria.
- Events classified as severe harm or death are also included.
- Total SRE count = Process 1 + Process 2 + Never Events.
Behavioral Events
- Physical Contact (Assault) - patient, visitor, staff.
- Sexual Assault, Rape or Indecent Exposure
- Missing Patient - abduction or missing minor (newborn to 13 years old).
- Patient Restraint Process - incorrect patient.
- Unauthorized Acts - care provided by bogus professionals.
- Self-Harming Behavior - actual self-harm, attempt/gesture, other forms, suicide (actual or attempt).
- Use/Possession of Prohibited/Stolen Goods - unauthorized use of weapon.
Blood/Plasma Products
- Administration to Incorrect Patient
- Patient Monitoring During and Post-Transfusion - death suspected due to transfusion, transmission of chronic/fatal disease.
Discharge of a Patient
- Discharge of a Patient Unable to Make Decisions - to unauthorized person.
Diagnostic and Therapeutic Events
-
Performed on Incorrect Patient
- Diagnostic Conclusions
- Assessment/Evaluation/Examination/Triage
- Investigations/interpretations
- Radiological/Imaging Investigations/Interpretations
- Monitoring of Patient Status
- Non-invasive Treatment Process/Procedure
- Patient Restraint Process
- Radiation Therapy
- Missing Laboratory Investigations - irreplaceable biological specimen (e.g., biopsy).
- Artificial Insemination - wrong donor sperm or egg.
- Resuscitation Process - performed on incorrect patient.
- Radiation Overdose - due to wrong treatment or environmental hazard.
Environmental Hazards
- Exposure to Hazardous Substances - blood, body fluids, sharps injury, eye splash.
- Unsafe Environmental Conditions - hospital evacuation, explosion, fire, radiation overexposure.
- Falls - resulting in intracranial injury, fracture, dislocation, laceration, death, paralysis, coma, or major permanent loss of function.
Medical Devices/Equipment/Supplies
- Implantable Device - event resulting in removal of device.
- User/Utilization Process - incorrect patient.
Medication
- Administration to Incorrect Patient
-
Patient Monitoring
- Adverse drug reaction (including post-immunization).
- Medication error resulting in patient death, paralysis, coma, or other major permanent loss of function.
Medical Gas Events
- Administration to Incorrect Patient - Incorrect gas/gaseous mixture, or gas contaminated by a toxic substance.
Nutrition (Pharmacy Products)
- Administration to Incorrect Patient
Unexpected Deaths or Severe Harm
- Unrelated to the patient’s natural course of illness or underlying condition.
Perinatal Events
- Maternal Death
-
Maternal Injury to Body Part, Organ, or Vasculature
- Unscheduled hysterectomy
- Uterine rupture
- Ureter, bladder, bowel, vasculature injury
- Perineal tear or laceration (3rd or 4th degree)
- Other injury to body part, organ, or vasculature
- Perinatal Event - Unexpected death intra-uterine, intra-partum, or post-partum.
-
Neonatal
- Subdural or cerebral hemorrhage
- Injury to brachial plexus (Erb's or Klumpke's paralysis)
- Clavicle fracture
- Hypoxic ischemic encephalopathy (HIE)
- Seizure(s)
- Exchange transfusion for severe hyperbilirubinemia
- Exposed to wrong breast milk
- Sent home with the wrong parents
- Unexpected death
Perioperative Events
-
Anesthesia Care (including conscious sedation)
- Incorrect patient
- Incorrect inhalation anaesthetic agent/gas mixture or dose
- Incorrect non-inhalation anaesthetic agent or incorrect dose
- Failed intubation
- Insufficient airway management
- Insufficient sustainment of general anaesthesia
- Failure to recognise and respond to significant change in patient status
- Death - intraoperative or postoperative.
-
Physiological Complications - not present prior to surgery
- Air embolus
- Iatrogenic pneumothorax
- Paralysis, coma, or major permanent loss of function
- Burn - e.g., diathermia and/or operating room fire.
- Unintended Laceration or Puncture - diagnosed or not managed during primary procedure.
- Organ Transplant - unintended transplanting of contaminated organs or tissues.
Personal Property/Data/Information
- Confidentiality/Privacy Breach - intentional or unintentional.
- Unauthorized Access/Disclosure
Pressure Injury
- Hospital-Acquired - Stage 3, Stage 4, Unstageable.
- Present on Admission But Deteriorated in Hospital - Stage 3, Stage 4, Unstageable.
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Description
This quiz focuses on Serious Reportable Events (SREs) in the healthcare sector, including Never Events and various behavioral incidents. It discusses the classification, significance, and implications of these events in patient safety and practice. Test your knowledge on how these events are categorized and the necessary responses required.
