From the Director
Two years after the 1999 Institute of Medicine’s ground-breaking report To Err Is Human shocked clinicians and the public alike by highlighting the many thousands of U.S. deaths each year due to medical errors, AHRQ commissioned the report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. This report examined the evidence behind nearly 80 patient safety practices and became the cornerstone of efforts to rank safety practice by the strength of the evidence. At that time, hospitals and health care organizations were under relatively little pressure to implement safety practices. But a decade later, regulators and accreditors are pushing health care organizations to adopt safe practices and health care organizations themselves are making patient safety one of their top priorities. For example, most hospitals now have patient safety officers.
AHRQ’s new evidence report Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices assessed evidence for 41 patient safety strategies and most strongly encourages adoption of the top 10 (see box on page 3). The patient safety practices fall into three categories: (1) those aimed at a specific patient safety target, such as adverse drug events, or specific clinical topics, such as preventing pressure ulcers; (2) those designed to improve the overall system or to address multiple patient safety targets, such as nurse-staffing ratios or computerized provider order entry; and (3) crosscutting patient safety practices, such as those that promote a culture of safety or team training.
Our new report, described on this month’s cover, took a step further by examining more than the evidence for the effectiveness of each patient safety practice. It also examined the scope of the problem targeted by the safety practice, its potential for harmful unintended consequences, costs to implement it, and difficulty of implementation. In this way, the report reflects the growing recognition of the importance of context and implementability of patient safety practices and informs health care providers about the costs and ease or difficulty of implementing certain practices. The report strongly encourages health care providers to adopt 10 patient safety practices and encourages them to adopt another 12. Although further research will continue to refine these recommendations, our report shows that there is enough evidence now to permit health care systems to adopt strategies we know will protect patients and save lives.
Carolyn Clancy, M.D.