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NQF Endorses 34 Safety Practices in Latest Manual

Janice Simmons, for HealthLeaders Media, April 13, 2010

The National Quality Forum (NQF) has released its fourth updated edition of its Safe Practices for Better Healthcare manual. The 34 endorsed safety practices included in the manual—ranging from surgical site infections prevention to informed consent to medication reconciliation—have some slight changes from the previous year.

However, the manual’s message is that much still needs to be done with patient safety—especially in light of the fact that medical related harm as a cause of death in the U.S. has gone up from the eighth leading cause in 1999 to the third leading cause currently, according to the NQF.

Nearly 15 million instances of medical harm occur annually in the U.S. The costs associated with medical harm have been estimated to cost between $17 billion and $29 billion per year in healthcare expenses, lost worker productivity, lost income, and disability, according to NQF.

The release of the report was announced Monday in Washington, D.C., by actor Dennis Quaid whose newborn twins accidentally received very high doses of the blood-thinner Heparin shortly after the were born in 2007. Quaid, who subsequently went on to create a foundation focused on patient safety, cited the need for more technology to alleviate errors. (The foundation has since merged with the Texas Medical Institute of Technology safety program.)

"All humans make mistakes. Human error combined with systems failures causes the majority of harm due to medical accidents," Quaid said. "I'm an actor. If I make a mistake, I have take two or take three or four or 37. Believe me, I've been there. But if a caregiver makes a mistake it can mean somebody's life."

"Hospital staff more often than not are working without a safety net. [They are] working sometimes double shifts and expected to make crucial decisions with clarity and judgment for every patient in their care—often without any backup expect the overworked caregiver working beside them," he said.

He called for closer attention to be paid to innovative technologies that can help caregivers. "Healthcare needs more of what the airline industry figured out a long time ago: Safety-centered design and technological backup [is needed] for human-factors related error," he said. These are technologies such as barcode systems, smart infusion pumps, and computer physician order entry.

"It is time to make a call to action to encourage policy makers to tie the NQF's safe practices to healthcare reform," he said. "Challenge hospital leaders to adopt them and ask the public to demand them."

In the latest manual, 34 practices are organized into seven functional categories for improving patient safety:

  • Creating and sustaining a culture of safety informed consent, life sustaining treatment, disclosure, and care of the caregiver
  • Matching healthcare needs with service delivery capability
  • Facilitating information transfer and clear communication
  • Medication management
  • Prevention of healthcare associated infections
  • Condition and site specific practices

The 2010 manual also includes contributions from patient advocate experts on "examples of the themes that are believed to be important for patients and families to consider during their healthcare encounters."


Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.

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