Protocol Development and Quality Improvement
Topic
Measure
Stroke Measure (STK) Set
| • | Discharged on antithrombotic therapy (STK-02) |
|---|---|
| • | Anticoagulation therapy for atrial fibrillation/flutter (STK-03) |
| • | Antithrombotic therapy by the end of hospital day 2 (STK-05) |
Venous Thromboembolism (VTE) Measure Set
| • | Venous thromboembolism prophylaxis (VTE-1) |
|---|---|
| • | Intensive Care Unit Venous Thromboembolism Prophylaxis (VTE-2) |
Sepsis Measure
| • | Severe sepsis and septic shock: Management bundle (SEP-1 Composite Measure) |
|---|
Mortality Measures
| • | Hospital 30-Day, All-cause, Risk-Standardized Mortality Rate following Acute Ischemic Stroke |
|---|
(MORT-30-STK)
Readmission Measures
| • | Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (AMI Excess Days) |
|---|---|
| • | Excess Days in Acute Care after Hospitalization for Heart Failure (HF Excess Days) |
| • | Excess Days in Acute Care after Hospitalization for Pneumonia (PN Excess Days) |
Safe Use of Opioids
| • | Safe Use of Opioids – Concurrent Prescribing |
|---|
CMS PSI 04
| • | Death rate among surgical inpatients with serious treatment complications |
|---|
Hospital Harm
| • | Severe hypoglycemia (HH-01) |
|---|---|
| • | Severe hyperglycemia (HH-02) |
| • | Opioid-related adverse events (HH-ORAE) |
CMS = Centers for Medicare & Medicaid Services; FY = fiscal year; IQR = inpatient quality reporting.
Information from: Centers for Medicare & Medicaid Services (CMS). CMS Measures Inventory Tool. Available at https://www.qualityreportingcenter.com/
globalassets/2024/01/iqr/01.-iqr_fy-2026_cms-measures_vfinal508.pdf
Nonprofit organization responsible for targeting medication error prevention and safe medication
use; a certified patient safety organization
Based on a nonpunitive approach and system-based solutions
Five key areas of focus: Knowledge, analysis, education, collaboration, and communication
| d. | Medication Errors Reporting Program – Practitioner self-reporting program |
|---|
ISMP Quarterly Action Agenda and Bi-weekly Safety Alerts
Can review bi-weekly and conduct gap analysis to proactively identify at-risk safety concerns.
ii.
All bi-weekly newsletters are combined into a quarterly action agenda to review and identify
areas for opportunity to improve safety in medication use processes.
ISMP Targeted Medication Safety Best Practices for Hospitals (2024–2025)
Worksheet can be used to perform a gap analysis of an institution’s performance with medication
safety issues that continue to cause fatal and harmful errors to patients.
ii.
The interactive worksheet can be found at https://www.ismp.org/resources/worksheet-ismp-
targeted-medication-safety-best-practices-hospitals.