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Pressure Ulcer

Below are detailed descriptions of reportable adverse events, grouped by state or federal agency. Answer the question that appears beneath EACH description. When you're finished, click View Reporting Instructions to move to the next page.

Department of Public Health

Serious Reportable Event

The following must be reported as an SRE:

  • Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a health care setting.

A pressure ulcer that was staged at Stage 3 upon admission and that progressed to Stage 4 should be reported as a serious incident, rather than an SRE.

DPH offers the following additional guidance:

  • Report these as SREs:
    • Stage 3 ulcers that were either not present or were Stage 1 ulcers on admission to your hospital;
    • Stage 4 ulcers that were not present, were Stage 1 or were Stage 2 ulcers on admission; and
    • Unstageable ulcers that were not present, were Stage 1 or were Stage 2 ulcers on admission.
  • Pressure ulcers that developed in areas where deep tissue injury was documented as present on admission/presentation are not SREs.
  • If a patient who is seriously critically ill (e.g., patients with multi organ failure, patients for whom routine turning and repositioning poses a significant risk to their respiratory or cardiovascular status, or patients for whom turning is physically prohibitive) develops a reportable pressure ulcer, alert DPH. DPH will make a case-by-case determination as to whether or not the pressure ulcer should be considered an SRE.
  • For reporting purposes pressure ulcer stages are defined according to the National Pressure Ulcer Advisory Panel definitions.

You are required to report an SRE that occurred at another hospital or ambulatory surgery center if you provided services that resulted from the event. You do not have to report the SRE if you have reason to believe the other facility has already reported it to DPH.

Reference: M.G.L. c. 111, § 51H, 105 CMR §§ 130.332, 140.308; DPH, 2012 SRE Reporting Guidance; Circular Letter #12-9-570; Circular Letter (Pressure Ulcers Update) #13-7-593

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The Serious Incident section will become available only if “No” or “Unsure” is selected. Otherwise, by selecting ‘yes’ you will be given directions for reporting an SRE that may also be a serious incident.

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Serious Incident

DPH requires you to report any incident that seriously affected the health and safety of a patient or that caused serious physical injury to the patient.

Note that this includes a pressure ulcer that was staged at Stage 3 upon admission and that progressed to Stage 4. This should be reported as a serious incident, rather than an SRE.

DPH uses the term “serious incident” to cover several broad categories of reportable events. In addition to the above, it also includes any of the following:

  • A patient death that is:
    • Unanticipated
    • Unrelated to the natural course of the patient’s illness or underlying condition, or
    • The result of an error
  • Full or partial evacuation of the facility for any reason
  • Fire
  • Suicide
  • Serious criminal acts
  • Pending or actual strike action by its employees, and contingency plans for operation of the hospital;
  • Surgery and anesthesia-related complication(s) that result in serious morbidity or death of a patient.

These events are reportable if they occurred on premises covered by your facility's license.

Reference: 105 CMR § 140.307. (Note that DPH has the regulatory authority to add to this list of serious incidents through guidance.)

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Quality and Patient Safety Division, Board of Registration in Medicine

Major Incident

QPSD requires you to report any major or permanent impairment of bodily functions or death of a patient not ordinarily expected as a result of the patient's condition on presentation. This is a Type 4 major incident.

Note that it is expected that all events reported to the Department of Public Health as SREs will also be reported to QPSD as major incidents. In addition, QPSD encourages facilities to identify, analyze and report “near miss” incidents.

QPSD defines major impairment as a significant change in the patient’s functional status either physically or mentally.

For your information, there are 3 other types of major incidents, which are reportable to QPSD regardless of the patient’s underlying condition.

  • Type 1. Maternal death related to delivery,
  • Type 2. Death in the course of, or resulting from, elective ambulatory procedures,
  • Type 3. Any invasive diagnostic procedure or surgical intervention performed on the wrong organ, extremity or body part.

Reference: 243 CMR § 3.08(2)

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