Patient Safety Measures: Complications 

Project Status: Completed

Patient Safety Measures: Complications Endorsement Maintenance

NOTE: NQF-endorsed® patient safety measures endorsed before June 2009, as well as new patient safety measures with a focus on high-volume complications including pressure ulcers, falls, venous thromboembolism, healthcare-associated infections (HAIs), safe discharge, avoidance of readmission, and medication safety, were reviewed in this project.

Access the Endorsement Summary (PDF) | Access the Phase 1 Report | Access the Phase 2 Report 

The Opportunity

Medical errors and unsafe care kill tens of thousands of Americans each year. NQF’s National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infection Data reports that “an estimated 2 million HAIs alone occur each year in the United States, accounting for an estimated 90,000 deaths and adding $4.5 billion to $5.7 billion in healthcare costs.”1 The Enters for Disease Control and Prevention (CDC) estimate that HAIs cost U.S. hospitals at least 5.7 billion per year, and potentially up to $31.5 billion.2 

Falls and pressure ulcers are also high cost and high volume adverse events. Falls are the leading cause of injury-related death for individuals 65 and older, and it is estimated that patient falls among the elderly will cost over $30 billion by 2020.3,4 In 2007, there were 257,412 reported cases of Medicare patients who had a pressure ulcer as a secondary diagnosis during hospitalization—these cases had an average charge of $43,180.5 In addition, beginning October 1, 2008, Medicare no longer reimburses for either the extra cost of treating Category/ Stage III and IV pressure ulcers that occur while the patient is in the hospital or the extra cost of treatment for serious injuries resulting from falls.

HAIs, falls, and pressure ulcers, while occurring in relatively high numbers, are only a few of the many types of patient safety-related events that occur in healthcare settings. The costs are passed on in a number of ways—premiums, taxes, lost work time and wages, and health threats, to name a few. Proactively addressing unsafe care will protect patients from harm and lead to more affordable, effective, and equitable care.

About the Project

This project began in June 2011.


This project sought to identify and endorse new performance measures for accountability and quality improvement that address patient safety, and, specifically, complications of health care. Additionally, consensus standards related to patient safety endorsed by NQF before 2009 also will be evaluated under the maintenance process. This project is being conducted in two phases. The first phase addressed measures related to venous thromboembolism, medication safety, and surgical safety, among other subjects. Topics addressed in the second phase included falls, pressure ulcers, and healthcare associated infections.

NQF Process

Measures were considered for NQF endorsement as national voluntary consensus standards. Consensus on the recommendations developed through NQF’s format Consensus Development Process (CDP, Version 1.8).

NQF Member and public comment was sought on all parts of the project.


This project was supported under a contract provided by the Department of Health and Human Services in support of the Affordable Care Act (ACA).

Related NQF Work

  • National Quality Forum (NQF), Serious Reportable Events in Healthcare–2011 Update, Washington, DC: NQF; 2011, In press.
  • NQF, Safe Practices for Better Healthcare–2010 Update, Washington, DC: NQF; 2010.
  • NQF, National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infection Data: A Consensus Report, Washington, DC: NQF; 2008.

Contact Information

For further information, email


  1. NQF, National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infection Data: A Consensus Report, Washington, DC: NQF; 2008.
  2. Scott RD,The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases; Coordinatging Center for Infectious Diseases, Centers for Disease Control and Prevention; March 2009.
  3. CDC, 2006: Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at Last aceessed October 30, 2009.
  4. UlrichR, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004 Sept.
  5. Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy -- a consensus paper from the International Expert Wound Care Advisory Panel. Adv Skin Wound Care 2008; 21:469-470, 472-478. 

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