AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk

Interim Report to the Senate Committee on Appropriations

As a result of its hearings, the Senate Committee on Appropriations directed the Agency for Healthcare Research and Quality (AHRQ) to lead the national effort to combat medical errors and improve patient safety. This report provides the requested Interim Report to the Committee and is a status update on AHRQ's entire Patient Safety Initiative.

Contents

Summary
Chapter 1. AHRQ's Medical Error Reporting Demonstration Evaluation Projects: Key Issues in Identifying Threats to Patient Safety
   Background
   16 Medical Error Reporting Demonstration Evaluation Grants Awarded
   Preliminary Observations
   Summary
Chapter 2. Efforts to Reduce Medical Errors: AHRQ's Response to Senate Committee on Appropriations Questions
   How are Hospitals and Other Heath Care Facilities Reducing Errors?
   How Do Health Care Professionals Share Strategies?
   How Many Hospitals and Other Health Care Facilities Record and Track Medical Errors?
   How Is Medical Error Information Used to Improve Patient Safety?
   What Incentives and/or Disincentives Have Helped Health Care Professionals Reduce Medical Errors?
   Most Common Root Causes of Medical Errors
   How Effective are State Reporting Systems?
Chapter 3. AHRQ's Patient Safety Initiative: Breadth and Depth for Sustainable Improvements
   Congressional and IOM Guidance Lead To Major Role for AHRQ in Patient Safety
   AHRQ's Long-Range Plan to Address Patient Safety
   Background: Four Elements Supporting AHRQ's Patient Safety Initiative
   Developing the Foundation: A Portfolio of Activities
References
Acronyms
Appendix 1. Patient Safety Terms and Definitions
Appendix 2. The Medical Error Reduction Demonstration Program: Abstracts of 16 Demonstration Evaluation Grants