The Opportunity 

Medical errors and preventable patient harms continue to occur at unacceptably high rates despite decades of efforts to remediate these events. A 2022 report from the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that 25 percent of Medicare patients were harmed during hospital stays in October 2018, and 43 percent of those were preventable. 

Unfortunately, the lack of reliable standardized reporting of patient safety events limits our ability to identify the factors contributing to patient harm and reduce preventable harm. Unaligned patient safety events reporting programs diminish efforts to systematically measure and report the prevalence and impact of harm events​. Disparate definitions and terminologies further hinder consistent interpretation of harm events and subsequent reporting adherence​. 

In its 2023 Report on Transforming Patient Safety, The President’s Council of Advisors on Technology and Science (PCAST) underscored the urgent need to upgrade public reporting of serious, avoidable harm events as a national priority for patient safety improvement. NQF’s Serious Reportable Events (SRE), or “Never Events,” first introduced in 2002 and maintained through periodic updates, defines serious, largely preventable, and harmful clinical events. It is used by national and state-based event reporting systems to increase accountability and improve patient safety. Today’s healthcare landscape has changed significantly since the list’s last update.  

About the Project 

NQF’s Focus on HARM (Harmonizing Accountability in Reporting and Monitoring) is a patient safety initiative that aims to reduce preventable harm by first modernizing the criteria for what constitutes an SRE and aligning standards for reporting such events across different accountability systems—an essential step to strengthen efforts to pinpoint and address the causes of preventable harm. 

Focus on HARM, a multi-stage public-private initiative, is addressing long-standing deficiencies in our nation’s ability to systematically measure, trend, and report patient safety events. This initiative is designed to drive sustainable reduction of preventable harm events.  

Contact Information

For more information, please contact the project team at patientsafety@qualityforum.org