Leapfrog's CEO Comments on Proposed Changes to Serious Reportable Events Definition

January 22, 2010

Leah Binder, CEO of The Leapfrog Group, serves on the National Quality Forum's Serious Reportable Events (SREs) Steering Committee, as the only purchaser representative. She was one of two Committee members who recently voted in opposition to changing the SRE definition from "events that should never occur" to "events that should not occur."

Ms. Binder commented:

The word "never" in the SRE's definition sparked a new word in the lexicon of American healthcare: "never events". Purchasers and patient advocates tend to be passionate about "never events", because removal of the wrong limb in surgery, for example, goes beyond physical harm; it is a profound violation of the trust we must place in the institutions that care for us in our most vulnerable moments of life.

Some argue that in rare cases SREs occur that were not preventable, and so the term "never" is unfair to providers. But when we think about killing a patient through transfusion of the wrong blood, "never" should be the goal, if sadly not always the reality. Setting a standard of "never" does not mean we expect providers to achieve perfection, it means we expect them to aim for it.

The word "never" is simply a more emphatic version of "not", and emphatic is a proper posture when describing how the health system should approach these disturbing tragedies. Perhaps that's just semantics, but downgrading the emphasis from "never" to "not" sends a powerful and disheartening message to the public and purchasers, and words do matter.

To view the committee's proposed changes and submit a public comment, click here.


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