AHRQ Report Reviews 47 Practices To Improve Patient Safety

Press Release Date: March 10, 2020

A new report from the Agency for Healthcare Research and Quality (AHRQ) reviews 47 practices that target patient safety improvement in hospitals, primary care practices, long-term care facilities and other healthcare settings. The report, Making Healthcare Safer III, was published today as AHRQ joins others in observing Patient Safety Awareness Week.

“As we implement 21st century healthcare, we need to make sure that all patients are getting the highest quality and safest care possible,” said AHRQ Director Gopal Khanna, M.B.A. “With this report, AHRQ is seeking to support a culture of safety across the entire healthcare ecosystem. We expect this report to shape the national, regional, and local patient safety agendas for years to come.”

The 47 patient safety practices (PSPs) are categorized in major topic areas, such as:

Medication management.
Healthcare-associated infections (HAIs).
Nursing-sensitive practices.
Procedural events.
Diagnostic errors.
Crosscutting factors.

These areas include PSPs such as clinical decision support technologies, use of rapid-response teams, special hygiene and disinfection interventions to prevent HAIs, and several practices designed to prevent medication errors and reduce opioid misuse and overdose.

Despite sustained national attention and notable successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, HAIs, falls and obstetric adverse events are blamed for thousands of deaths and hundreds of thousands of injuries each year. AHRQ statistics (PDF) estimate that in 2017, there were 86 hospital-acquired conditions per 1,000 hospital discharges—a figure that has fallen steadily in recent years but remains alarmingly high.

Making Healthcare Safer III addresses this by supporting the implementation of PSPs where appropriate, advancing a framework for patient safety transformation and considering the contextual factors that can lead to successful use of patient safety interventions.

“Before clinicians commit to implementing a patient safety practice, they want to know that they won’t be wasting their precious time and resources,” said Jeffrey Brady, M.D., director of AHRQ’s Center for Quality Improvement and Patient Safety. “This report provides information the field needs to evaluate how to prioritize efforts to keep patients safe.”

The report calls for more research specifically into what makes for successful implementation of a patient safety intervention, a call that Dr. Brady echoed. “With patient safety, we increasingly know what to do—but often the challenge is how to make improvements work in the context of a specific facility or setting and have them succeed in the real world,” he said.

This is AHRQ’s third Making Health Care Safer report and was produced under a contract to Abt Associates and IMPAQ International. The first two reports, published in 2001 and 2013, have each served as a consolidated source of information for healthcare providers, health system administrators, researchers and government agencies.

Patient Safety Awareness Week

is an annual health observance sponsored by the Institute for Healthcare Improvement. As the Nation's patient safety agency, AHRQ supports this event to increase awareness about patient safety among health professionals, patients, and families.

AHRQ, part of the U.S. Department of Health and Human Services (HHS), is the nation’s lead health services research and patient safety agency. Its mission is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable, and to work within HHS and with other partners to make sure that the evidence is understood and used.

Editor’s Note: A video, complete list of the 47 patient safety practices, and full report are available here.

Contact:

Karen Carp, AHRQ Office of Communications
Karen.Carp@ahrq.hhs.gov or 301-427-1858