The National Quality Forum (NQF) – an affiliate of The Joint Commission – launched a “Focus on HARM” patient safety initiative to address the high rates of avoidable medical errors and preventable patient harms that continue 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% of Medicare patients were harmed during hospital stays in October 2018, and 43% of those were preventable.
The Focus on HARM (Harmonizing Accountability in Reporting and Monitoring) initiative will begin by re-examining the most egregious events, often referred to as “Never Events” because they should never occur in healthcare. These events were first defined by NQF in 2002 with the introduction of the Serious Reportable Event (SRE) list. To be included on the SRE list, harmful clinical events must be serious, unambiguous, and largely preventable. The list is used by national and state-based event reporting systems to increase accountability and improve patient safety. Currently, 28 states and the District of Columbia use the SRE list or elements of it for mandatory accountability reporting.
Focus on HARM 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. Today’s healthcare landscape has changed significantly since the list’s last update – care is increasingly delivered in different settings and modalities, including ambulatory care facilities, home care, and telehealth – necessitating a review of the SREs and the specifications used to define them.
“The lack of reliable, consistent, objective data standards related to measuring patient safety events limits our ability to quantify the magnitude of the problem and track our progress as we mitigate avoidable patient harm,” said Dana Gelb Safran, ScD, NQF president and CEO. “This work represents a critical and overdue step needed to enable systematic measurement, tracking, and improvement as we continue national efforts to make healthcare safe for every patient, every time, in every setting.”
A new on-demand webinar is available from Becker’s Hospital Review on “Elevating Sustainable Healthcare Practices.” Healthcare plays a vital role in human well-being, yet its impact on carbon emissions is significant and frequently underestimated. Recognizing this challenge, The Joint Commission has launched the Sustainable Healthcare Certification program for U.S. hospitals and critical access hospitals. This program provides a structured framework to guide leadership and governance in setting priorities and developing skills to minimize waste and carbon footprint.
Seattle Children's is a trailblazer in adopting innovative strategies to reduce anesthesia-related emissions. Leveraging electronic health record (EHR) data in AdaptX, the hospital dramatically reduced anesthesia-related emissions by 87%, equivalent to 500,000 kg of carbon dioxide annually. These improvements yielded substantial cost savings, exceeding $175,000 per year, without compromising patient outcomes. Following Seattle Children’s success, a multi-institutional quality improvement consortium, Project Spruce, was launched, targeting a 50% reduction in anesthesia-related greenhouse gas emissions across 12 participating hospitals.
The webinar provides more information about how:
- The Joint Commission's Sustainable Healthcare Certification program guides hospitals in waste reduction and carbon footprint reduction.
- Seattle Children's innovative strategies and use of EHR data led to an impressive 87% reduction in anesthesia-related emissions.
- Seattle Children’s success sparked an international quality improvement initiative, Project Spruce.
Presenters include The Joint Commission’s Chad Larson, executive director, Hospital Accreditation Program; and from Seattle Children’s, Elizabeth Hansen, MD, PhD, pediatric anesthesiologist, assistant professor at University of Washington, founder of Project Spruce; and Dan Low, MD, pediatric anesthesiologist, chief medical officer, AdaptX.