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Summary of Patient Safety Research Opportunities

AHRQ Summit and Roundtable on Research Priorities for Patient Safety Improvement

Research questions, topics, and key themes that were addressed as part of the Patient Safety Roundtable and Patient Safety Summit included the items listed below. It is important to note that the field of patient safety is extensive and that it touches every patient, practitioner, and healthcare stakeholder. The patient safety research opportunities identified during the course of meeting preparations and the meetings themselves are the result of one of many important efforts to consider how to address the substantial toll that results from threats to patient safety. As a result, this listing of important questions that research could answer is also one input among many that can help to guide AHRQ’s patient safety research agenda.

The systemic nature of many safety challenges is well-documented, and this characteristic can make it difficult to ‘exclusively’ classify problems and solutions that are needed into discrete categories. Nevertheless, the following interconnected themes emerged and are used in this document to categorize and highlight areas of focus that were identified as part of these meetings.

Key questions that patient safety research could address have been organized according to these themes.

Impacts of COVID on Patient and Healthcare Workforce Safety in all Healthcare Settings

  1. What are the collective patient safety impacts of the COVID pandemic and the changes in care delivery due to COVID on patients in ambulatory healthcare settings, nursing home residents, home health care patients, and patients in acute care hospitals?
  2. How do the social restrictions (e.g., visitation policies) for preventing COVID that have been implemented in nursing homes and other settings of care affect residents’ and patients’ physical and emotional health?
  3. As health systems adjust to create surge capacity for COVID-19 patients, how was/is patient safety affected for other patients? (For example, those who experienced shifts to telehealth or disruptions of planned and routine care, such as cancellations or postponements of elective surgeries or scaled-back chronic care management.)
  4. Based on the experience of COVID, what important lessons learned have emerged regarding effective strategies for communications about patient safety during a public health crisis? How can community preparedness be measured for a public health crisis, and how can preparedness plans ultimately impact patient safety?
  5. What is the full extent of the physical and psychological effects of the pandemic on the healthcare workforce, and how are these burdens impacting the safety of the care they are able to deliver?
  6. Which strategies for mitigating the physical and psychological effects of the pandemic on the healthcare workforce have been most successful? How can these strategies be implemented most effectively?
  7. How can nursing home staff protect themselves from contracting COVID outside the workspace?
  8. How can we strengthen the public health approaches to COVID prevention in nursing homes?
  9. Does combining employee safety and patient safety increase the pace and extent of improvement in safety in healthcare organizations (all settings)?
  10. Can we impact staff perception of organizational safety culture in long-term care through innovative strategies to address staff physical and psychological safety?

Effects of Social Determinants of Health and Systemic Racism on Patient Safety

  1. What is the impact of socio-economic status on the risk for adverse events or patient safety events? How can the impact of socio-economic status on patient safety events be measured?
  2. What are the patient safety effects of limited access to essential health care services, and how do they disproportionately affect caregivers and families who belong to AHRQ’s priority populations [list priority populations]?
  3. What factors influence trust between patients (particularly minority patients) and the healthcare system? What strategies have been successful in improving trust between patients and their providers?
  4. How can the patient safety effects of disparities in COVID testing, treatment, and outcomes across medically underserved populations be prevented?
  5. What are the patient safety impacts of the COVID-19 response on those patients who have been effectively “displaced” from their usual source of care?

Understanding and Reducing Harm caused by Diagnostic Errors

  1. How are diagnostic errors within and across healthcare settings affecting the safety and quality of care that is delivered to patients?
  2. What is the effect of the rapid and substantial increase in the use of telehealth on the accuracy and timeliness of diagnoses?
  3. What are the safety concerns, including delayed or missed diagnoses, due to lack of in-person exam/vital signs? There is an existing need for better algorithms to define what is appropriate for video visits, balancing patient’s desires for convenience and clinical need.
  4. Do algorithms created with expanded clinical documentation (e.g., symptoms, signs, SDOH, accurate problem list, accurate medications) lead to reduced harm from diagnostic error compared to algorithms produced solely with data available in EHRs?
  5. What are the most appropriate measures for diagnostic accuracy and timeliness?

Patient Safety Across the Continuum of Care

  1. What is the full set of threats that patients and providers face across the entire continuum of care? The field lacks the kind of useful information that would be provided by a comprehensive, community-based, patient-centered, longitudinal descriptive epidemiological study to better understand patient safety.
  2. How can providers more seamlessly coordinate care transitions within and across various health settings? How might an optimal patient tracking system work across the continuum of care? How could hand-offs be standardized to facilitate improved care coordination?
  3. How can we better facilitate patient monitoring in between ambulatory care visits?
  4. How can findings from successful patient safety studies be quickly and efficiently translated into broad-scale, routine, clinical practice? Which research studies are replicable across healthcare settings? For example, do successful safety practices in the hospital setting also reduce medication errors when applied in other settings? If not, could they be adapted effectively?

Patient and Family Engagement and How it Can Support Patient Safety

  1. How can partnerships with patients evolve to be more consistent across the healthcare industry?
  2. How can patients be more engaged in the design of patient safety research studies, measurement, and improvement?
  3. What are the information and training needs of caregivers, and how can providers optimally support caregivers in ways that promote patient safety?
  4. How can the field improve patient-clinician communication and shared decision making?
  5. What metrics and care models can be used to evaluate acute episodic care and continuity linkages for complex care across the continuum that promote self-care and independence as long as possible especially for those most vulnerable?
  6. Patient and Family Engagement Research Program: What are the implications of engaging users of healthcare services (e.g. patients, family caregivers or LTC residents) in co-designing and implementing interventions to improve patient safety outcomes or patient safety culture?
  7. How could research and improvement projects be most effectively carried out to address the following priorities for patient and family engagement:
    1. informed consent interventions designed to reduce harm events,
    2. interventions focused on improving the discharge process and follow up care at home,
    3. interventions that increase effective measurement of harm events, including psychological/emotional harm,
    4. interventions that expand collection and analysis of patient reported outcomes
    5. interventions that expand patient/family/resident engagement in organizational governance and priority-setting,
    6. interventions that expand patient/family/resident engagement in organizational outcomes improvement work, and
    7. interventions designed and implemented to expand or improve digital communication between providers and users of care; e.g., telehealth, access to data, and use of portals and apps?

Technology and its Impact on Patient Safety (e.g., digital healthcare, Health IT, Electronic Health Records, and telehealth)

  1. What is the full set of risks and benefits of telehealth with respect to patient safety, including comparisons of the rates of misdiagnosis, populations that may be lost to care, delays in accessing care, challenges for patient-provider communication, and problems associated with care transitions? How can threats to patient safety that are associated with telehealth be mitigated?
  2. What training needs and competency requirements are necessary for a provider to safely deliver care using telehealth?
  3. What are the most effective financing approaches for telehealth that would simultaneously maintain benefits and safeguard against risks? Telehealth has been an important and pivotal resource during COVID-19, yet reimbursement challenges remain for payers and providers in most settings. For example, in the home health setting, telehealth visits are not reimbursable.
  4. How can providers ensure patient centeredness and ‘meeting patients where they are’ as a driving factor for the use of telehealth?
  5. What collateral benefits might be possible as a result of the rapid growth in telehealth, such as expanded opportunities mentorship of clinicians, and how can those benefits be optimized?
  6. How do we understand and measure the cognitive burden imposed by IT systems in the delivery of healthcare? What systems-based approaches can be used to improve the delivery of healthcare and support the needs of clinicians, patients and caregivers?
  7. What are the IT infrastructure needs across all healthcare settings, and how could necessary functions such as a national reporting system for digital health safety events (likely intensified by COVID and the increased use of telehealth) be established in a way that supports safer care?
  8. What are the patient safety implications of digital health technologies and different modalities of accessing care, and which subpopulations may have more challenges accessing and using care during a digital transformation across all settings?
  9. How can audiovisual recordings of patient care events be created in a manner that is: HIPPAA complaint, legally protected, and most effectively used to improve human and system performance and enhance patient safety?
  10. What are the unexpected consequences of the widespread adoption of EHRs?
  11. How can adverse event detection be automated through the use of EHRs?
  12. How to create reliable, standardized, interoperable information systems for tracking and ensuring fail safe follow-up of test results that require action, referrals and consultations?
  13. How can we improve and leverage clinical documentation to enhance ease of entry, meaningful display, and capture of clinicians' thinking/assessment?
  14. How can we overcome barriers and operationalize the implementation of indications based prescribing of medications, laboratory, radiology, and other clinical testing?

Expanding Research about Preventing Healthcare-Associated Infections

  1. How can organizations balance the need for infection control and prevention with priorities that matter to patients, families and caregivers?
  2. How can research address surveillance for candida auris transmissibility and mitigation strategies in hospitals and nursing homes?
  3. What approaches can evaluate effective strategies for post discharge device care and post op wound infection prevention?
  4. What are effective measures to curb emergence of antibiotic resistance in post-acute care settings?
  5. How do we improve antibiotic use in outpatient settings?
  6. How can we bolster infection control efforts in long term care facilities?

Optimizing Research Methods for Patient Safety Improvement

  1. What are the most effective models for scaling improvements in patient safety? What can be done immediately to increase the rate of improvement and harm reduction on a larger scale?
  2. How can dissemination and implementation theory and methods be more substantially and consistently applied to patient safety improvement?
  3. How could funding mechanisms support more rapid cycle, implementation-oriented research?
  4. How might research on implementation support the development of an adaptable implementation framework for all healthcare settings?
  5. What strategies are effective for connecting and coordinating the activities of researchers and stakeholders who use or could use their research? How do we foster and enable truly partnered research that brings together operational partners who are involved in design, planning and execution, in ways that helps to overcome barriers to improvement?

Enhancing Measurement and the Effective use of Data for Improving Patient Safety

  1. What approaches for patient safety measurement are most productive for supporting patient safety improvement? How can patient safety measurement be standardized across settings?
  2. How could safety leaders engage clinicians to improve the consistency of reporting patient safety events across settings?
  3. How do we design safety databases to ensure the availability of socio-demographic patient variables so they enable sufficient stratification for these factors?
  4. What data is necessary to enable comparisons of safety based on the type of patient care and interaction that occurred (i.e., in-person visit, virtual video, virtual phone, etc.)?
  5. How can measurement systems represent the patient perspective in ways that are important for improving patient safety? What approaches would integrate the patient/caregiver voice in reporting patient safety events and enlist patients and caregivers in helping to mitigate harm before it occurs?
  6. What research and development is needed to design real time measurement capabilities for patient safety events? What changes in practice and workflow are needed to effectively integrate timely measurement with interventions to improve patient safety?
  7. What are the most compelling options for reframing the costs, harms, and other outcomes associated with patient safety threats and the potential returns on investment (ROI) for improvement and prevention? For example, for problems that require systems-based solutions, do options for framing ROI that apply a systems-based perspective help organizations better understand and realize benefits that are based on the relationships between investments in improvement and desirable outcomes? How do organizations assess improvement opportunities such as the implementation of communication and resolution programs and the associated improvements in safety outcomes and reductions in liability costs, etc.?
  8. What are the major barriers healthcare delivery organizations face when they attempt to apply the findings from patient safety research? Which strategies are most effective for different kinds of organizations as they seek to translate research findings into changes in their processes for improving patient safety that are operationally feasible?
  9. How can we improve data collection and reporting on patient safety goals, including healthcare associated infections?
  10. Can we achieve improved quality and safety outcomes in aging services communities through application of a proactive collaborative safety model of reporting and continuous improvement that is based on safety science (versus a more reactive, punitive approach to oversight)?
  11. How do we create a balance between safety and quality of life for residents receiving care and services in long-term care settings? How do we know whether we are achieving a good balance (what is the measurement for this?)? How do we honor quality-of-life choices while being held accountable for safety outcomes?
  12. Patient safety and quality of care are focal points for all healthcare organizations. Medical errors, inconsistent practices, and variable outcomes of care still affect patient confidence in our delivery of healthcare. Despite the numerous initiatives being in place since the IOM report was released, patient safety improvements have been modest, at best. Can patient safety be defined at an organizational level, and, if so, how can it best be measured and monitored?
  13. While at present an organization is required to participate in Leapfrog for example as a means for demonstrating a measure for patient safety, with all the data currently submitted to CMS by hospitals, what applicable measures could be assembled that could demonstrate/reflect an organizational "composite score" for patient safety?

Strengthening Healthcare Infrastructure for Patient Safety

  1. How does organizational design influence patient safety, and how can systems ensure that safety is embedded in their cultures and supported by well-designed processes and systems for delivering care? 
  2. How is patient safety affected when healthcare systems that are working at maximum capacity experience surges in demand? What experiences from systems such as emergency departments could help inform the adaptations needed for other healthcare settings?
  3. What is the ideal amount of reserve capacity or “slack” that should be available to enable responses to surges in demand, so that acceptable levels of patient safety are preserved? 
  4. What are the most effective and cost-efficient training strategies for frontline workers in high turnover positions? 
  5. How can organizations effectively address staffing challenges and provide for sustainable personnel and leadership models that ensure patient safety? What staffing strategies for positions that are difficult to recruit and retain are most effective in-home health, long term care, and nursing home settings? How can the healthcare sector ensure a sustainable cadre of leaders who are qualified to mitigate the effects of: clinician burnout, morale (especially for lower-paid positions), and other threats to patient safety?
  6. How do healthcare workers make decisions and balance resources in ways that maintain both productivity and safety?
  7. How can we better understand and design clinical systems to be more supportive of healthcare workers? 
  8. How can systems engineering principles be used to identify the relevant hospital systems and subsystems, their acceptable ranges of performance, and the necessary operating procedures that are required to maintain performance within those ranges that are required for patient safety?
  9. What approaches help senior administrative leaders understand the effects of their decisions on safety and errors?
  10. How important is the manager's role in consistently producing highly reliable outcomes?
  11. What is the role of staff resilience in producing highly reliable outcomes?
  12. How important is implementation of Just Culture principles in producing highly reliable outcomes?
  13. What are best evidence-based methods for establishing a Just Culture in hospitals?
  14. How can we reinforce findings that show Communication and Optimal Resolution programs (e.g. CANDOR) can reduce risk in all healthcare settings while saving significant costs to health systems?
  15. How can AHRQ support pilot programs related to the creation of a National Patient Safety Authority?
  16. What are effective models/frameworks for providing a base level of knowledge and application of safety science concepts and strategies at all levels of an organization in aging services? What are the unique needs of aging services providers that impact content and implementation strategies?
  17. What hospital-based support systems best reduce cognitive load for clinical staff?
  18. What would be a practicable patient safety core curriculum for ambulatory care staff training for small and medium-sized practices (this curriculum would include tools, methods, and incentives)?
  19. Care Culture Research Program: What are the implications of interventions designed to foster and sustain organizational cultures that prioritize prevention of harm to patients, their families, and healthcare workers? Priorities:
    • Interventions to measure systemic, comprehensive implementation of CANDOR
    • Interventions designed to reduce workplace violence
    • Interventions designed to increase psychological safety in the workforce and reduce burnout
    • Interventions to engage and incentivize executive leaders to foster and sustain care cultures that prioritize prevention of harm to patients, their families, and healthcare workers
Page last reviewed March 2021
Page originally created March 2021

Internet Citation: Summary of Patient Safety Research Opportunities. Content last reviewed March 2021. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html

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