Comments to National Quality Forum (NQF) 2025 Serious Reportable Events List
The Alliance submitted comments to the National Quality Forum (NQF) request for stakeholder input on its proposed updates to its Serious Reportable Events (SRE) List. The Alliance focused on a problematic update to SRE 15: "Patient Harm Associated With a Stage 3 Pressure Injury, Stage 4 Pressure Injury, or Deep Tissue Injury Acquired After Admission." The 2025 update identifies 27 areas as serious reportable events and expands all SREs to all healthcare settings. The Alliance recommended not only that SRE 15 “not be expanded to other healthcare settings since it is totally different and unique from others that are currently on the list” but also that it be removed from the list entirely. “Pressure ulcers/pressure injuries can be a normal physiologic response to the underlying co-morbid illnesses and acute hemodynamic factors and are not in the same category as operating on the wrong patient or wrong site, an overdose of radiotherapy, or insemination with the wrong sperm -- events that are clearly identifiable to a provider.” If NQF is not willing to delete SRE 15 from the 2025 list, the Alliance recommended that it limit the healthcare settings to only hospital/acute care and eliminate ambulatory/outpatient, post-hospital/subacute and home care. “Given the delay from event to presentation of a pressure ulcer/pressure injury, it will be impossible to reliably link them to an outpatient healthcare encounter,” the Alliance wrote.
