To guide healthcare systems in providing care that is free from error and harm the National Quality Forum (NQF) is releasing its 2009 Safe Practices for Better Healthcare. To accelerate the pace of adoption of Safe Practices nationwide, a year-long Webinar series will begin in April to provide Safe Practices implementation strategies and commentary from experts in the field.
"The Safe Practices offer clear tools for those who provide, purchase, and use healthcare to ensure that harm is reduced and care is safe. While improvements have been made in patient safety, they must spread farther and faster," said Janet Corrigan, NQF president and CEO. "We cannot afford -- in lives or dollars -- to provide care that is unsafe. Every patient deserves safe, high-quality healthcare, every time they receive care."
Preventable errors cost the United States an estimated 98,000 lives annually, $17 billion to $29 billion per year in healthcare expenses, lost worker productivity, lost income, and disability.(1) Even more troubling, while healthcare spending grows more than seven percent per year, it is estimated that patient safety is improving by only 1 percent or 2 percent.(2)
One of the major barriers to improvement is an inability to share information and data regarding what works in real-time or even nearly real-time. Research has shown that an average of 17 years elapse before evidence-based practices are incorporated into widespread clinical practice, and then the application of the knowledge is inconsistent.(3) The healthcare system is notoriously fragmented with poor communication between practitioners at all levels. Poor communication has been cited as the most frequent root cause of medical errors accounting for more than 60 percent of events between 2006 and 2008.(4)
Similarly, it is well recognized that committed and informed leadership within healthcare systems will not only improve the functioning of a healthcare organization, but also its overall culture and the approaches to patient safety practices. Direct involvement of patients and families in the processes of care with open, transparent communication also improves patient safety. Both the roles of leadership and patient and family engagement are important components in the 2009 Safe Practices.
"Safe Practices are intended to provide a roadmap for hospitals and health systems to improve safety. By focusing on an evidence-based systems approach we hope to provide guidance to clinical leadership to make wise decisions about implementing programs and policies to measurably improve safety," said Gregg Meyer, senior vice president of the Center for Quality and Safety at
The NQF-endorsed Safe Practices and year-long Webinar series are tools to help unite healthcare providers, purchasers, and consumers to more rapidly identify and adopt established techniques and routines that reduce errors and improve care. The Webinars, which begin in April and continue throughout the year, will provide Safe Practices implementation strategies and commentary from experts in the field. Each Webinar will address specific safe practices to guide the healthcare industry in more rapid adoption of safety practices. For example, one of the Webinars will address measurement and public reporting for improvement -- an area NQF advocates as part of any reform strategy.
"This is the most harmonized and evidence based set of practices ever assembled -- with consensus across major stakeholders from virtually every sector of healthcare," said Charles Denham, MD chairman of TMIT and co-chair of NQF's 2009 safe practices maintenance committee. "Adoption of these practices will save lives, save money, and build valuable trust in the communities we serve."
The evidence-based practices endorsed by NQF build on six years of work defining and refining strategies that improve the safety of healthcare. Thirty-four practices are included in 2009 Safe Practices. New practices were added in areas such as pediatric imaging, glycemic control, organ donation, catheter-associated urinary tract infection, and multi-drug resistant organisms. A number of previously endorsed practices were updated based on new evidence, including practices in areas such as the pharmacist's role in medication management and pressure ulcers, and an entire chapter on healthcare-associated infections.
NQF joins leading healthcare organizations in celebrating Patient Safety Awareness Week, March 8-14, 2009. The National Patient Safety Foundation's, Patient Safety Awareness week is designed to engage staff, patients, and community by emphasizing the critical need for partnership and participation in the drive for a safer healthcare system.
This project was funded by the Texas Medical Institute of Technology.
1. IOM, To Err Is Human: Building a Safer Health System.
2. Catlin A, Cowan C, Heffler S, et al., National health spending in 2005: the slowdown continues, Health Affairs, 2007;26(1):142-153.
3. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Fact Sheet. AHRQ Publication No. 04-P014, March 2004. Agency for Healthcare Research and Quality,
4. The Joint Commission. 2008 National Patient Safety Goals. 2008. Available at http://www.jointcommission.org/NR/rdonlyres/82B717D8-B16A-4442-AD00-CE3188C2F00A/0/08_HAP_NPSGs_Master.pdf. Last accessed November 7, 2008.; Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Jt Comm J Qual Patient Saf 2007 Sep;33(9):576-83.
Source: National Quality Forum