Bridging Efforts to Improve Patient Safety and Public Health | Agency for Healthcare Research & Quality

Bridging Efforts to Improve Patient Safety and Public Health | Agency for Healthcare Research & Quality

Bridging Efforts to Improve Patient Safety and Public Health

By Jeffrey Brady M.D., M.P.H., Director of AHRQ Center for Quality Improvement and Patient Safety

In an ideal world, health care would be completely free of harm. 

Thanks to concerted national efforts, we’re moving closer to this ideal. Harm is occurring less frequently in hospitals, according to a report AHRQ released last year. We estimated that 87,000 lives were saved and $20 billion in excess costs were avoided thanks to a 17 percent decline in hospital-acquired conditions from 2010 to 2014.

These numbers show progress. But they also show the magnitude of the patient safety challenges we still face. The estimated number of lives saved as a result of our national success during this 4-year period of progress exceeds the number of deaths from breast cancer nationally every 2 years.  This improvement is both substantial and unprecedented, but 121 instances of harm still occur for every 1,000 discharges from the hospital. That’s why the work we have ahead of us is so important. Patient Safety Awareness Week  is a good time to renew our focus on reducing harm, spread and reinforce what we have learned, and make sure that everyone is applying this safety knowledge.  Patient safety needs to stay at the top of our agenda, not only this week, but all year.

AHRQ is the lead patient safety agency within the Department of Health and Human Services. We develop knowledge and tools to help clinicians in the field understand what they can do to keep patients safe, and we help with practical approaches and support that also address how to do it. The foundation of patient safety knowledge that AHRQ has built over the last 15 years has been a major driver for this national public health effort to make care safer.

Building on what we’ve learned about safety in hospitals, we’re increasing our efforts to expand knowledge and make practical tools available to improve patient safety in all settings of care.  This week, we are launching a new version of TeamSTEPPS® tailored for medical offices to help them improve communication, teamwork, and mutual support.  Called TeamSTEPPS for Office-based Care, it builds on successful TeamSTEPPS principles and shows how they can be applied in this setting.

This tool and others like it reflect AHRQ’s ongoing commitment to improve safety everywhere. We recognize that adverse events don’t occur in isolation, but rather are the product of their environment. So we support and fund health services research that advances our understanding and solves a wide range of patient safety challenges that patients and providers encounter across the care continuum. For instance, AHRQ co-sponsored the 2015 Institute of Medicine Report Improving Diagnosis in Health Care , which highlights the need to make inroads in diagnostic safety and improve diagnosis in health care, especially in the ambulatory setting. We’re moving forward, taking the report’s recommendations to heart.

AHRQ’s evidence-based tools often have originated in hospitals. However, the demand for patient safety solutions extends beyond the inpatient setting. We are working diligently to provide nursing homes, primary care practices, and ambulatory facilities tools to address safety issues. For example, we have developed a family of five patient safety culture surveys for hospitals, medical offices, nursing homes, community pharmacies, and ambulatory surgery centers to help professionals in these settings understand their safety culture and how they can improve it.

It’s important to engage health care staff in pursuit of safer health care. It’s equally important to engage patients and their families. We can develop and implement evidence-based practices, but if patients are disengaged, we miss important opportunities to prevent harm. That’s why AHRQ has expanded its tools for patients and families and enhanced initiatives to engage them as partners.

Bringing patient safety to the forefront and developing the evidence base to make care safer is a huge task. AHRQ can’t do it alone. That’s why we work with our Federal partners and others to bring proven practices to the front lines of care.  Researchers can contribute by submitting ideas about how to make care safer. Research funding opportunitiesare available on the AHRQ Web site. We’re particularly interested in medication safety, ambulatory care, healthcare-associated infections, and diagnostic safety. New knowledge in these and other areas will form the basis for further progress to keep patients safe. 

Solutions to public health challenges such as preventing harm in health care often require the commitment of many stakeholders. Effective collaboration among many, including government agencies, health care providers, patients, families, and the community, will bring us closer to achieving higher patient safety standards and reduced harm.  This Patient Safety Awareness Week, let’s rededicate ourselves to a shared commitment to pursue the safest possible care for all patients. 

You can learn more about AHRQ’s role in patient safety in the video by Bruce Siegel, M.D., M.P.H., President and CEO of America's Essential Hospitals, and the video by patient advocate, Sue Sheridan, M.B.A., M.I.M., D.H.L., Director of Patient Engagement for the Patient-Centered Outcomes Research Institute.

Page last reviewed March 2016

Internet Citation: Bridging Efforts to Improve Patient Safety and Public Health. March 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/blog/ahrqviews/bridging-efforts-to-improve-patient-safety.html