Making Health Care Safer II

An Updated Critical Analysis of the Evidence for Patient Safety Practices

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices (AHRQ Evidence Report No. 211) updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). The 2001 report analyzed the strength of evidence for patient safety practices in use at that time. The 2013 report analyzed a growing body of patient safety research to determine the level of evidence regarding the outcomes, as well as implementation, adoption, and the context in which safety strategies have been used.

After analyzing 41 patient safety practices, an international panel of patient safety experts identified 22 strategies that are ready for adoption. Enough evidence exists that health systems and institutions can move forward in implementing these strategies to improve the safety and quality of health care.

To access Making Health Care Safer II(AHRQ Evidence Report No. 211), go to www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

To access Making Health Care Safer (AHRQ Evidence Report No. 43), go to http://archive.ahrq.gov/clinic/ptsafety/.

Of the 22 strategies identified in Making Health Care Safer II, 10 are "strongly encouraged" for adoption based on the strength and quality of evidence:

  1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
  2. Bundles that include checklists to prevent central line-associated bloodstream infections.
    Tools for Reducing Central Line-Associated Bloodstream Infections
    CUSP Toolkit
  3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
    On the CUSP: Stop CAUTI
  4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
  5. Hand hygiene.
    Centers for Disease Control and Prevention hand hygiene resources
    Department of Veterans Affairs hand hygiene resources
  6. "Do Not Use" list for hazardous abbreviations.
    The Joint Commission, Facts About the Official "Do Not Use" List
  7. Multicomponent interventions to reduce pressure ulcers.
    The On-Time Quality Improvement for Long-Term Care
  8. Barrier precautions to prevent healthcare-associated infections.
    Tools for Reducing Central Line-Associated Bloodstream Infections
  9. Use of real-time ultrasound for central line placement.
    Tools for Reducing Central Line-Associated Bloodstream Infections
  10. Interventions to improve prophylaxis for venous thromboembolisms.
    Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement
    Blood Thinner Pills: Your Guide to Using them Safely
    Your Guide to Preventing and Treating Blood Clots

Making Health Care Safer II also identifies 12 patient safety strategies that are "encouraged" for adoption based on the strength and quality of evidence: 

  1. Multicomponent interventions to reduce falls.
    Preventing Falls in Hospitals
    TeamSTEPPS Long-Term Care Version
  2. Use of clinical pharmacists to reduce adverse drug events.
    Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
    The Pharmacy Health Literacy Center
    Blood Thinner Pills: Your Guide to Using them Safely
    Pharmacy Safety Culture Survey ( PDF Version [ PDF file - 506.51 KB] )
  3. Documentation of patient preferences for life-sustaining treatment.
  4. Use of informed consent to improve patients' understanding of the potential risks of procedures.
  5. Team training.
    TeamSTEPPS®
  6. Medication reconciliation
    Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
    RED (Re-Engineered Discharge) Toolkit [New toolkit available on March 5]
    Pharmacy Safety Culture Survey ( PDF Version [ PDF file - 506.51 KB] )
  7. Practices to reduce radiation exposure from fluoroscopy and computed tomography scans.
  8. Use of surgical outcome measurements and report cards, such as the American College of Surgeons National Surgical Quality Improvement Program.
  9. Rapid response systems
    TeamSTEPPS, Rapid Response Module
  10. Utilization of complementary methods for detecting adverse events/medical errors to monitor for patient safety problems.
    AHRQ Common Formats
    AHRQ Quality Indicators™ Toolkit for Hospitals
  11. Computerized provider order entry.
  12. Use of simulation exercises in patient safety efforts.
    Training Guide: Using Simulation in TeamSTEPPS Training

Annals of Internal Medicine Supplement

A special supplement to the Annals of Internal Medicine features 10 articles on selected patient safety strategies http://www.annals.org/issue.aspx?journalid=90&issueid=926462  featured in Making Health Care Safer II. Each article in the supplement is followed by a continuing medical education quiz for clinicians.

A limited number of copies of this supplement (AHRQ publication number OM13-0032) are available from the AHRQ Publications Clearinghouse. To order, contact the Clearinghouse via Email at AHRQpubs@ahrq.hhs.gov or call 800-358-9295. 

Current as of March 2013
Internet Citation: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html