NATIONALCONSENSUSSTANDARDSFORSAFER.ppt

NATIONAL CONSENSUS STANDARDS FOR SAFER HEALTHCARE Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum August 25, 2003 “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.” Presentation Overview The occurrence of medical errors What is the NQF NQF activities in patient safety Priority strategic actions Serious Reportable Events ‘Safe Practices’ Patient Safety Taxonomy Performance measures WHAT DO WE KNOW ABOUT THE OCCURRENCE OF MEDICAL ERRORS? “I would give great praise to the physician whose mistakes are small for perfect accuracy is seldom to be seen” Hippocrates “. . . even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable.” Florence Nightingale, 1863 “…Serious and widespread quality problems exist throughout American medicine. These problems….occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result….” Code Words for Medical Errors Healthcare Errors – How Big is the Problem? 3-38% of hospitalized patients affected by iatrogenic injury or illness 44,000-98,000 hospital deaths/year IOM 2-35% of hospitalized patients suffer adverse drug events average 7% 7,000 ADE deaths/year 2 million nosocomial infections/year What is the role of the NATIONAL QUALITY FORUM? WHAT IS THE NQF The National Quality Forum is a private, non-profit voluntary consensus standards setting organization. WHAT DOES THE NQF DO The NQF was established to improve the quality of U.S. health care by: standardizing health care performance measurement and reporting; designing an overall strategy and framework for a National Healthcare Quality Measurement and Reporting System; and othe