Patient Safety 2015-2017 

Project Status: Completed

Patient Safety Project 2015-2017

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.”

The Institute of Medicine report Preventing Medication Errors identifies error rates across a variety of settings and types, estimating that about 400,000 preventable adverse drug events (ADEs) occur each year in U.S. hospitals; another 800,000 in long-term care, and more than 500,000 among Medicare patients in outpatient settings. The report also notes that costs associated with preventable medication errors have not been well researched but conservatively estimates that the annual cost to hospitals of the 400,000 ADEs, in 2006 dollars, was $3.5 billion.

HAIs and preventable medication errors, while occurring in relatively high numbers, are only two 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 medical errors and unsafe care will protect patients from harm and lead to more affordable, effective, and equitable care.

NQF has a ten-year history of focusing on patient safety. Through various projects, NQF has previously endorsed over 100 consensus standards related to patient safety. In addition, NQF endorsed 34 safe practices in the 2010 update of the Safe Practices for Better Healthcare and 29 Serious Reportable Events (SRE). The Safe Practices, SREs, and NQF-endorsed patient safety measures are important tools for tracking and improving patient safety performance in American healthcare. However, significant gaps remain in the measurement of patient safety. There is also a recognized need to expand available patient safety measures beyond the hospital setting and harmonize safety measures across sites and settings of care. In order to develop a more robust set of safety measures, NQF will be soliciting patient safety measures to address environment-specific issues with highest potential leverage for improvement.

About the Project

The Patient Safety project is entering its third cycle. 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. This project will address topic areas including but not limited to:

  • Fall screening and risk management
  • Medication reconciliation
  • Measures from applicable settings, such as skilled nursing facilities and inpatient rehabilitation facilities
  • Unplanned admission-related measures from other settings (i.e., hospitalization for patients on dialysis)
  • All-Cause and condition specific admission measures
  • Condition-specific readmissions measures
  • Measures examining length of stay

The Patient Safety project will also review measures that are eligible for maintenance, including measures targeting mortality rates, fall rates, medication safety, and pressure ulcer prevalence.

NQF Process

Candidate consensus will be considered for NQF endorsement as national voluntary consensus standards. Consensus on the recommendations will be developed through NQF’s formal Consensus Development Process (CDP, Version 1.9). This project involves the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a Standing Committee.


This project is funded under NQF’s contract with the Department of Health and Human Services, Consensus-based Entities Regarding Healthcare Performance Measurement.

For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit:

Related NQF Work 

Contact Information

For further information, contact Andrew Anderson, MHA, Project Manager via email at

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