In 2002, prompted in part by the release of the 1999 Institute of Medicine report titled "To Err is Human: Building a Safer Health System," the NQF created a list of 27 Serious Reportable Events, which was expanded to 28 events in 2006. The NQF defines these events as errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients. The IOM also concluded that medical errors including those that result in hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion.

In addition to the administrative actions being taken, specific legislative proposals were included in the President's FY 2009 budget submitted to Congress that would have prohibited Medicare payment for never events and would have required hospitals to report never events or receive a reduced annual payment update.


The IPPS rule adds conditions, including one NQF never event, to the list of conditions that have been determined to be reasonably preventable through proper care. Beginning last year, as required by the Deficit Reduction Act of 2005 (DRA), CMS began selecting hospital-acquired conditions (HACs) that were determined to be reasonably preventable. If a condition is not present upon admission, but is subsequently acquired during the hospital stay, Medicare will no longer pay the additional cost of the hospitalization. The patient is not responsible for the additional cost. Rather, the hospital is being encouraged to prevent an adverse event and improve the reliability of care it is giving to Medicare patients.

In last year's final rule, CMS listed eight preventable conditions for which it would not make additional payments. In this year's proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these. The new additional conditions in this year's final rule include:

· Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity

· Certain manifestations of poor control of blood sugar levels

· Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures



The final rule issued also expands the Reporting Hospital Quality Data for Annual Payment Update Program. The Medicare law requires CMS to reduce payments to hospitals that do not successfully report quality measures adopted under the program by two percent from the percentage increase that would otherwise apply to their payment rates. The quality measures are publicly reported on the CMS Hospital Compare Web site, a tool that can be used by beneficiaries in choosing where to receive treatment.

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