Appendix: Background Information

Background information that was highlighted for attendees prior to the AHRQ Summit and Roundtable on Research Priorities for Patient Safety Improvement follows.

Safer Together: A National Action Plan to Advance Patient Safety

The National Action Plan, developed with the involvement of more than 30 organizations who have an interest in improving patient safety, was published on September 14, 2020. The Plan provides recommendations that health care leaders, delivery organizations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care. The Plan is organized according to 4 foundational areas that are considered necessary for safe health care by the National Steering Committee for Patient Safety, and recommendations in the report focus on these four foundational areas:

• Culture, Leadership, and Governance
• Patient and Family Engagement
• Workforce Safety
• Learning Systems

Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

Published in Spring 2020, this AHRQ evidence report reviews available scientific evidence for 47 practices that target patient safety improvement in hospitals, primary care practices, long-term care facilities, and other healthcare settings. The report also notes gaps in the evidence and identifies potential topics about which more research is needed in order to better understand and effectively implement safe practices.

Health Systems Respond to COVID-19: Priorities for Rapid-Cycle Evaluations

AcademyHealth launched a project on March 21, 2020, in response to COVID-19. The project identified priority questions health system leaders and care providers had (and were likely to continue to have over the next six to nine months). Topics of potential interest include health system and policy responses to COVID-19 and the impact (both intended and unintended) on health system policies, processes, providers, and patient care, including for those patients not directly affected by the virus. Patient safety issues and other concerns relevant to safety (e.g., health care resilience) are included among the topics, and many of these fall under a domain entitled, “Care Delivery, Management, Decision-Making, and Operations.”

AHRQ Patient Safety Network (PSNet)

PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more. The resource has catalogued more than 15,000 items in the collection and organizes these according to a robust taxonomy for patient safety.

National Health Quality Roadmap

This resource was published by the U.S. Department of Health and Human Services on May 15, 2020, and its purpose is to improve patient outcomes through the enhanced effectiveness and efficiency of federal investments in health care quality measurement. The roadmap identifies policy and regulatory levers to drive change in the federal Quality Measurement Enterprise, which the report specifies as including the broad array of organizations and individuals who develop and steward measures of health quality; collect and report data on those measures; and use quality measure information.