AHRQ Supports Hospitals As They Make Care Safer

Each year in the United States, millions of people are cared for in the Nation’s hospitals. In sometimes heroic efforts to heal patients or save lives, staff at these hospitals conduct countless surgical procedures and dispense untold amounts of medication. Most of this care is provided exactly as planned. But sometimes, despite the best efforts of clinicians, patients are harmed by the very care that is intended to make them better.

Hospital staff are some of the most dedicated in the health care system. They work long shifts in a complex environment with compassion and sometimes, even humor. This is why hospitals are such an important part of every community—and a valued partner to AHRQ as we continue to face the public health challenge of improving patient safety.

Hospitals have been working hard to make care safer, and National Hospital Week is an ideal time to recognize these significant contributions. According to an AHRQ report released late last year, from 2010 to 2014 hospital-acquired conditions (HACs) across the country dropped by 17 percent. We estimate that this reduction saved 87,000 lives and $20 billion in costs. (HACs are unintended events that happened to a patient during their hospital stay that shouldn’t have.)

It’s particularly important to remember this progress in light of a study published last week that estimates adverse events to be the third leading cause of death in the United States. That study is a sobering reminder of just how far we have yet to go.

At AHRQ we believe that just one death due to an adverse event is too many. That’s why we’ve developed the research and tools that many hospitals and health care workers are using day in and day out to make care safer.

We have a suite of research-based tools to help hospitals establish a culture of safety and teamwork so clinical teams can more effectively tackle patient safety issues and reduce harm in their facility. Some of the resources hospitals use most are:

• TeamSTEPPS®, a customizable, module-based teamwork and communication training program for clinicians that has specialized tools to reduce patient safety risks
• The Comprehensive Unit-Based Safety Program (CUSP) Toolkit, a highly effective method of preventing healthcare-associated infections (HAIs) that combines improvement in safety culture, teamwork, and communication together with a checklist of proven practices
• Hospital Survey on Patient Safety Culture and other Patient Safety Culture Surveys that can help health care providers in various care settings examine patient safety culture from the staff perspective

Many other AHRQ resources are used across all areas of hospitals, from the emergency room to discharge. For example, our Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4 is a triage process to help hospital emergency department staff quickly identify those patients in need of immediate attention. Nurses who have used this tool tell us that the algorithm helps them manage patients more appropriately.

To help avoid medication mix-ups and adverse drug events, we developed the Medications at Transitions and Clinical Handoffs (MATCH) Toolkit that features strategies from the field to improve medication reconciliation processes for patients as they move through the health care system. And when patients are ready to go home, our Re-Engineered Discharge Toolkit helps hospitals make sure patients have the information they need to take care of themselves when they leave the hospital.

Through our Healthcare-Associated Infections Program, we produce tools and resources to help hospitals, long-term care facilities, and ambulatory care settings prevent HAIs. Reducing HAIs and antibiotic resistance are both national priorities where AHRQ plays an important role.

As the lead Federal Agency for patient safety, AHRQ salutes hospitals for the hard work they’ve done to make care safer over the last several years. Our work is not done, however. We look forward to continuing to collaborate with hospitals and others in the health care field to discover ways to make care safer and develop the practical tools and resources that help those on the front lines keep patients safe from harm.