Massachusetts: Avoidable Hospital Errors Continue To Plague Quality Care

Tracking 29 Things That Should Never Happen in a Hospital

Despite a reputation for excellence and innovation, Massachusetts hospitals can sometimes be dangerous places. In an effort improve patient safety, the state Department of Health tracks “serious reportable events” also known as "never events" — avoidable adverse events that should never happen in a hospital.

As defined by Massachusetts law,* a serious reportable event (SRE) is an event that results in a serious adverse patient outcome that is clearly identifiable and measurable, reasonably preventable, and that meets any other criteria established by the department in regulations.
* Section 51H of Chapter 111 of the General Laws

The total number of SREs in Massachusetts acute care hospitals in 2017 was 922. Some of the most common avoidable errors included:

  • Falls = 308
  • Pressure ulcers = 294
  • Surgery on wrong site = 49
  • Medication errors = 52
  • Foreign objects left in patient = 31

Total Number of SREs in Acute Care Hospitals by Year

** Two events in 2015 and 2016 affected a large number of patients and is reflected in the increase in SREs reported. Data abstracted on Jun 15, 2018 from the Health Care Facility Reporting System.

Massachusetts Serious Reportable Events

Below are the 29 preventable adverse events that Massachusetts tracks and must disseminate publicly in an effort to improve patient safety. This is the most recent data from 2017, which shows still too many SREs — over 900 for the year.

Surgical or Invasive Procedure Events
1. Wrong body part, side or site surgery of procedure = 49
2. Wrong patient surgery or procedure = 1
3. Wrong surgery or procedure performed = 8
4. Foreign object left in patient after procedure unknowingly = 31
5. Death of ASA Class I patient during surgery or within 24 hours = 0

Product or Device Events
6. Contaminated drugs, device or biologics = 21
7. Device misuse or malfunction = 21
8. Intravascular air embolism = 3

Patient Protection Events
9. Patient discharged to unauthorized person = 0
10. Serious injury or death during patient disappearance = 2
11. Suicide or self-harm = 25

Care Management Events
12. Serious injury or death from medication error = 52
13. Unsafe blood transfusion = 1
14. Maternal serious injury or death associated with labor or delivery = 7
15. Newborn serious injury or death associated with delivery = 11
16. Serious injury or death after a fall = 308
17. Stage 3, Stage 4 or unstageable pressure ulcer = 294
18. Artificial insemination with wrong egg or sperm = 0
19. Serious injury or death from loss of irreplaceable biological specimen = 2
20. Serious injury or death from lack of follow up or communication of lab result = 10

Environmental Events
21. Serious injury or death from electric shock = 0
22. Oxygen or gas delivery error = 2
23. Serious injury or death from burn = 25
24. Serious injury or death from physical restraints = 2

Radiology Events
25. Serious injury or death from metallic object in MRI = 0

Potential Criminal Events
26. Impersonation of a health care provider = 0
27. Abduction of patient = 0
28. Sexual abuse or assault of patient or staff member = 7
29. Serious injury or death after physicial assault of patient or staff = 41

Data source: Serious Reportable Events in 2017 Acute Care Hospitals, Non-Acute Care Hospitals and Ambulatory Surgical Centers, Bureau of Health Care Safety and Quality, Public Health Council, July 11, 2108

For more information, download the full report.

Previous reporting on Massachusetts SREs on the Patient Safety Blog:
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