Skip to main content Back to Top


NQF Says Public Should Know About Some Adverse Events

Kate Traynor

A report from the National Quality Forum (NQF) calls for at least a minimal degree of public disclosure when certain adverse events occur within health systems.

"Serious Adverse Events in Healthcare: A National Quality Forum Consensus Report," an NQF document released in February, defines 27 preventable adverse events that should be reported and investigated whenever they occur. Adverse events on the list that relate to pharmacy include:

  • The death or serious disability of a patient associated with the use of a contaminated drug, device, or biological product supplied by a health care facility,    
  • A medication error that results in a patient's death or serious disability, and    
  • The ordering or providing of health care by anyone who impersonates a pharmacist or other licensed health care provider.

In an appendix to the report, NQF stated that it devised the error list for use in state-based pilot projects, with the ultimate goal of creating a national health care error-reporting system. The nonprofit organization described public accountability for errors as the "primary purpose" of the error list. Information gleaned from error reports, according to the document, "should also be used to facilitate systematic quality improvement."

The NQF report called on individual states to decide how to disclose error data to the public. NQF suggested that the data could be disclosed in "de-identified" form or as "aggregated regional reports naming individual healthcare providers."

NQF noted in the report that the public should be educated about the conclusions that can be inferred from error data, which typically describe rare events. According to the report, rare events are not easily analyzed and do not allow for "fair comparisons" of health care institutions. NQF encouraged states to work together to produce regional, population-based error reports suitable for statistical analysis.