‘Focus on HARM’ initiative to refresh ‘Never Events’ to reflect the full range of today’s care delivery settings and develop consensus on reporting standards 4/04/2024

Washington, DC – The National Quality Forum (NQF) has 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 percent of Medicare patients were harmed during hospital stays in October 2018, and 43 percent 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.

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.

NQF founding CEO, Kenneth W. Kizer, coined the phrase “Never Events” in 2001 to describe particularly flagrant medical errors, such as a foreign object left inside a surgical patient. To be included on the SRE—or “Never Events”—list, harmful clinical events must be serious, unambiguous, and largely preventable. The list, maintained through periodic updates, 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.

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, President & CEO, NQF. “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.”

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