Medical error initiative from Joint Commission affiliate NQF targets preventable harm, “never events”

Editor's Note

Designed to address high rates of preventable medical errors, a new initiative from The National Quality Form (NQF), an affiliate of The Joint Commission, will modernize criteria for what constitutes a Serious Reportable Event (SRE) and align standards for reporting such events across different accountability systems. Dubbed “Focus on HARM” (Harmonizing Accountability in Reporting and Monitoring), the initiative was announced April 10.

According to the announcement, Focus on HARM’s work will begin with “Never Events”—a term first defined by NQF in 2002* with the introduction of the SRE list, now used in 28 states and the District of Columbia for accountability reporting. To be included in this list, a harmful clinical event must be serious, unambiguous, and preventable.

According to NQF, the evolution of healthcare toward ambulatory care, home care, and telehealth necessitates a review of SREs and how they are defined, providing the motivation for launching Focus on HARM. “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.”

*This news brief has been updated to reflect a correction. Before, it stated that "Never Events" was a term first defined by NQF in 2022; that has been changed to the correct year of 2002.