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National Quality Forum Finds Consensus on 30 Patient Safety Practices

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Press Release Date: May 15, 2003

Representatives of the nation's leading health care and consumer groups have endorsed 30 patient safety practices that should be universally used in health care settings to reduce the risk of harm resulting from processes, systems, or environments of care, according to a consensus report released today by the National Quality Forum and funded in part by the Agency for Healthcare Research and Quality.

Informing patients that they are likely to fare better if they have certain high-risk, elective surgeries at facilities that have demonstrated superior outcomes; specifying explicit protocols for hospitals and nursing homes to ensure adequate nurse staffing; hiring critical care medicine specialists to manage all patients in hospital intensive care units; making sure hospital pharmacists are more actively involved in the medication use process; and creating a culture of safety in all health care settings are among the 30 patient safety practices in the new report, Safe Practices for Better Healthcare: A Consensus Report.

"By achieving consensus on this set of evidence-based, high-priority safe practices, NQF seeks to stimulate their universal implementation in applicable health care settings and, in turn, achieve substantial improvements in patient safety," said NQF President and CEO Kenneth W. Kizer, M.D. The report is being released in Los Angeles at the NQF's meeting, Safe Practices for Better Healthcare: It's Time to Act.

The report reflects consensus among the NQF's 173 member organizations about the need to put better systems and procedures in place to help prevent medical errors like those outlined in a landmark 1999 Institute of Medicine report. NQF's member organizations represent all sectors of health care, including health care providers, consumers, employers, insurers, and other stakeholders. Among its members are the AARP, AFL-CIO, the American Hospital Association, the American Medical Association, the American Nurses Association, the American Society of Health-System Pharmacists, the Ford Motor Company, and General Motors.

The NQF consensus report is based in part on work by a team of researchers at AHRQ's Evidence-based Practice Center at Stanford University/University of California at San Francisco who identified 73 patient safety practices for which there were varying levels of scientific evidence in 2001. Numerous additional candidate measures were considered, and the 30 voluntary consensus standards in the NQF report were culled from a list of 220 candidate practices based on each practice's specificity, effectiveness, potential benefit, generalizability, and readiness for implementation. This report also identified 27 practices that have great promise for reducing adverse events and should have high priority for further research.

"If health care leaders work to implement this important set of voluntary consensus standards, it will go a long way toward preventing medical errors and improving patient safety," said AHRQ Director Carolyn M. Clancy, M.D. "This report, along with the findings from continuing patient safety research sponsored by AHRQ, will help make the nation's health care system a lot safer."

In addition to AHRQ, other agencies and organizations that provided funding for the report include the Centers for Medicare & Medicaid Services, the Robert Wood Johnson Foundation, the California HealthCare Foundation, the Horace W. Goldsmith Foundation, the Department of Veterans Affairs, the United Hospital Fund of New York, and the U.S. Office of Personnel Management.

A private, non-profit public benefit corporation, NQF was created in 1999 in response to the need to develop and implement a national strategy for health care quality measurement and reporting. Established as a unique public-private partnership, NQF has broad participation from more than 170 organizations that represent all sectors of the health care industry. Additional information about NQF and its projects is available at

Media interview requests should be directed to AHRQ's Karen Migdail at (301) 461-4741 or NQF's Robyn Nishimi at (202) 783-1300.

For more information, please contact AHRQ Public Affairs, (301) 427-1364: Karen Migdail (301) 427-1855 (


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