The Opportunity

The Institute of Medicine (IOM) defined patient safety as “freedom from accidental injury due to medical care or medical errors.”¹ Patient safety problems cause hundreds of thousands of preventable deaths each year—a recent analysis estimated that up to 440,000 Americans die annually from medical errors in U.S. hospitals.² A 2010 study by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) estimated that over a quarter of hospitalized Medicare beneficiaries experience an adverse event during their hospital stay; subsequent studies in other care settings estimated that the adverse event rates among Medicare patients in Skilled Nursing Facilities (SNFs) and rehabilitation hospitals are 33 percent and 29 percent, respectively. ^{3, 4, 5} Adverse events can take many forms, including healthcare-associated infections (HAIs), medication errors, falls, pressure ulcers, and other potentially avoidable occurrences. The costs of these events are high and are passed on in various ways—higher insurance premiums, taxes, lost work time and wages, and lower quality of life, to name a few. Proactively addressing patient safety will protect patients from harm and lead to more affordable, effective, and equitable care.

NQF Related Work

• Patient Safety Off-Cycle Review – 2017
• Patient Safety – 2017
• Identification and Prioritization of HIT Patient Safety Measures – 2016
• Improving Diagnostic Quality and Safety – 2017
• Patient Safety 2015 – 2016
• NQF-Endorsed Measures for Patient Safety – 2015
• Patient Safety Measures Complications Phase 1 – 2013
• Patient Safety Measures Complications Phase 2 – 2013

Stay Connected

For more information, please contact patientsafety@qualityforum.org.

1 Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

2 James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128.

3 HHS, Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: HHS; 2010.

4 HHS, Office of Inspector General (OIG). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. Washington, DC: HHS; 2014.

5 HHS, Office of Inspector General (OIG). Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: HHS; 2016.