Patient Safety 


Medical errors and unsafe care harm and kill tens of thousands of Americans each year. The facts are alarming: approximately two million healthcare-associated infections occur annually in the United States, accounting for an estimated 90,000 deaths and more than $4.5 billion in hospital healthcare costs. Unplanned, often preventable, hospital admissions and readmissions cost Medicare and the private sector billions of dollars each year and take a significant toll on patients and families, who suffer from prolonged illness or pain, emotional distress, and loss of productivity.

As a result, the National Quality Strategy has made making care safer a national priority, focusing on three goals:

  1. Reduce preventable hospital admissions and readmissions.
  2. Reduce the incidence of adverse healthcare-associated conditions.
  3. Reduce harm from inappropriate or unnecessary care.

Related NQF Work

  • NEW! Patient Safety 2015
    The Patient Safety project is entering its second phase. This project will evaluate measures related to patient safety that can be used for accountability and public reporting for all populations and in all settings of care.
     
  • NEW! HIT Safety
    NQF will explore the intersection of HIT and patient safety in order to create a report that will provide a comprehensive framework for assessment of HIT safety measurement efforts, a measure gap analysis and recommendations for gap-filling, and best practices and challenges in measurement of HIT safety issues to-date.
     
  • NEW! Surgery 2014
    The Surgery Project is now beginning its second phase. This project will include performance measures in the areas of general and specialty surgery that address surgical processes, including pre and post-surgical care, timing of prophylactic antibiotic, adverse surgical outcomes, and other related topics.
     
  • Patient Safety Measures
    NQF is seeking to endorse cross-cutting patient safety measures that span conditions, populations, and settings of care.
     
  • Prioritizing Measures: Health Workforce
    Health Workforce emphasizes the role of the workforce in prevention and care coordination, linkages between healthcare and community-based services, and workforce deployment. This project is one of five Prioritizing Measures initiatives.
    Access the Final Report
     
  • Infectious Disease Endorsement Maintenance 2012
    NQF sought performance measures that can be used for accountability and public reporting in topic areas related to infectious disease (viral, bacterial, fungal, or parasitic infections) for adults and children in all settings of care.
    Endorsement Summary
     
  • All-Cause Readmissions Measures Project
    In May 2012, NQF endorsed two measures that address all-cause unplanned readmissions in hospitals – an area of healthcare targeted for improvement given national imperatives to make healthcare safer, more affordable, and keep people healthy. Following an appeal in June, NQF upheld endorsement of both measures.
    Press Release | Endorsement Summary
     
  • Critical Paths: Patient Safety
    This project assessed the readiness of electronic data and health IT systems to support data capture, normalization, and standardization to support patient safety reporting and evaluation across clinical information systems, with a specific focus on acute care infusion devices. Read the Report 

  • Measure Applications Partnership (MAP)
    MAP has submitted a number of reports to the Department of Health and Human Services outlining strategies to help improve care through the selection of performance measures for public reporting and performance-based payment programs. Recent reports highlight the unique needs of the dual-eligible patients, hospice and palliative care patients, and PPS-Exempt Cancer Hospitals, including the importance of care coordination and patient and family engagement.
     
  • MAP Families of Measures: Safety and Care Coordination Task Force
    The Safety and Care Coordination Task Force have developed a "family" of aligned measures that includes available measures and measure gaps that span programs, care settings, and levels of analysis related to patient safety and care coordination. This family of measures addresses cost of care as related to these topics. Findings were included in the MAP Families of Measures Report, submitted to HHS on October 1, 2012.
     
  • National Priorities Partnership-Partnership for Patients
    The National Priorities Partnership (NPP) is a group of 52 major national organizations with a shared vision to achieve better health, and a safe, equitable, and value-driven healthcare system. The NPP oversees several initiatives of the Department of Health and Human Services’ Partnership for Patients initiative, including a patient safety webinar series and quarterly meetings to help meet the aims of the partnership.
     
  • NPP Readmissions and Maternity Action Teams
    NPP formed two Action Teams comprised of nearly two-dozen stakeholders representing providers, purchasers, consumers, health plans, accreditation and certification bodies, and state, regional and local entities. Focused on improving maternity care and reducing hospital admissions and readmissions across multiple care settings, each group has developed plans of action that address the who, what, how and when of reducing hospital readmissions and harm.
     
  • Patient Safety: Complications Phase I Measures Project
    In June 2012, NQF endorsed 14 patient safety measures with a focus on complications, addressing a range of quality concerns, including medication safety, venous thromboembolism, surgical safety, and care coordination. Two additional measures – focused on venous thromboembolism prophylaxis and current medication documentation in medical records – were endorsed in August 2012 following additional review from the project’s steering committee.
    Press Release | Endorsement Summary
     
  • Patient Safety: Healthcare-Associated Infections Measures Project
    In January 2012, NQF endorsed four patient safety measures focused on healthcare-associated infections. During this project, two similar and competing surgical site infection measures from the Centers for Disease Control and Prevention and the American College of Surgeons were harmonized with NQF’s support.
    Press Release | Endorsement Summary
     
  • Perinatal and Reproductive Health Measures Project
    In April 2012, NQF endorsed 14 quality measures on perinatal care. The measures address a wide range of care concerns, including childbirth, pregnancy and post-partum care, and newborn care. Several of the measures have the potential to dramatically affect the health and well-being of both mothers and newborns, including a measure focused on elective vaginal deliveries or cesarean sections before 39 weeks, as well as a measure focused on women receiving prophylactic antibiotics prior to a cesarean section.
    Press Release | Endorsement Summary
     
  • Serious Reportable Events (SRE) Project
    Preventing adverse events in healthcare is central to NQF's patient safety efforts. To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care.
     
  • Surgery Measures Project
    In January 2012, NQF endorsed 24 quality measures on surgical care performed in hospitals and in outpatient facilities, including measures focused on complications in patients undergoing hip and knee replacements; prophylactic antibiotic use in surgical patients; and mortality rates for patients experiencing complications. In May 2012, nine additional measures were endorsed as part of this work, including a new measure evaluating patient experience of care following surgical procedures.
    Press Release | Endorsement Summary
     

NQF Resources

The Field Guide is an online resource designed to help you easily access NQF resources.   

Find Measures

Use NQF's Quality Positioning System (QPS) to find measures related to Affordable Care.

Find measures now! 

Serious Reportable Events (SREs)

To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs).

Learn more about SREs