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The National Quality Forum (NQF), an affiliate of the Joint Commission, has launched a groundbreaking initiative called “Focus on HARM” to combat the persistently high rates of avoidable medical errors and preventable patient harm in healthcare. Despite decades of efforts to address these issues, a 2022 report by the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) revealed alarming statistics: 25 percent of Medicare patients experienced harm during hospital stays in October 2018, with 43 percent of those cases deemed preventable.  Examples of never-events in Acute Care Hospitals with behavioral health units, Psychiatric Hospitals, and Community Behavioral Health settings include but are not limited to:

  • Suicide or Self-Harm in a Controlled Environment
  • Unauthorized Release of Confidential Information
  • Physical or Sexual Assault Within a Treatment Setting
  • Medication Errors Resulting in Harm
  • Failure to Implement Adequate Suicide Risk Assessment and Management
  • Absconding or Elopement from a Secure Facility
  • Seclusion or Restraint-Related Injuries or Deaths

Preventable Patient Harm – A Focus on “Never Events”

The initiative, “Harmonizing Accountability in Reporting and Monitoring” (HARM), begins by revisiting the concept of “Never Events,” originally defined by NQF in 2002 as egregious medical errors that should never occur. The aim is to modernize the criteria for Serious Reportable Events (SREs) and standardize reporting standards across various accountability systems. This step is crucial for pinpointing the causes of preventable patient harm and implementing effective solutions.  Avoiding “Never Events” is a fundamental principle underlying the accreditation and regulatory frameworks from TJC, DNV, ACHC, CARF, COA, CHIQ, state regulatory agencies, and CMS

The healthcare landscape has evolved significantly since the last update of the SRE list, with care being delivered in diverse settings such as ambulatory care facilities, home care, behavioral health, and telehealth. Thus, it’s imperative to review and update the SREs to reflect the current healthcare environment accurately.

The Importance of Consistent Data

Dana Gelb Safran, President & CEO of NQF, emphasized the necessity of reliable and consistent data standards to measure patient safety events accurately. Without such standards, it’s challenging to quantify the magnitude of the problem and track progress in mitigating avoidable patient harm.

Moreover, the initiative has received support from various quarters, including The President’s Council of Advisors on Technology and Science (PCAST), which has highlighted the urgent need for public reporting of serious, avoidable harm events as a national priority for patient safety improvement.

Reducing the Burden on Healthcare Providers

One of the primary goals of the project is to reduce the burden on healthcare providers caused by multiple, differing reporting structures for patient safety events. In fact, by developing a consensus-based, unified framework for reporting standards, NQF aims to streamline the reporting process and improve accountability across healthcare systems and care settings.

In addition, Shantanu Agrawal, Chief Health Officer at Elevance Health, stressed the importance of streamlining taxonomies to reduce inconsistencies in data, which currently hinder efforts to track, compare, and reduce preventable patient harm.

A Look into the Future

Looking ahead, NQF plans to convene experts to develop novel approaches for improving and sustaining accountability for patient safety and harm reduction. The findings and recommendations will be shared with healthcare systems, federal and state agencies, and other organizations to strengthen safety improvement efforts across healthcare settings.

In conclusion, the “Focus on HARM” initiative by NQF represents a significant step forward in addressing preventable patient harm in healthcare. By updating reporting criteria, standardizing reporting standards, and fostering collaboration among stakeholders, the initiative aims to create a safer healthcare environment for all patients, regardless of care setting.

Barrins and Associates

Barrins can assist your organization to develop and implement a “Never Event” process to meet the unique needs of the population you serve. We also share our resources on best practices and strategies for efficiently and effectively developing and implementing a user-friendly “Never Event” program. 

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