Since the Institute of Medicine report "To Err is Human" was issued in 2000, the Agency for Healthcare Research and Quality (AHRQ) has served as the lead Federal agency to fund research and the development of tools and resources to improve patient safety. Through these activities, AHRQ seeks to prevent, mitigate, and decrease medical errors, patient safety risks and hazards, and quality gaps associated with health care and their harmful impact on patients. While we have made great strides in reaching this goal, and health care providers continue their efforts to deliver high-quality, evidence-based care, patients continue to be harmed by the health care system.
To address the need to improve patient safety and the medical liability system, the AHRQ Patient Safety and Medical Liability (PSML) Initiative was established in October 2009. Funding was intended to address four goals: (1) putting patient safety first by reducing preventable injuries, (2) fostering better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries while reducing malpractice litigation, and (4) reducing liability premiums.
Under the PSML initiative, AHRQ funded 13 planning grants and 7 demonstration grants. This initiative aimed to help States and health systems seek comprehensive solutions that improve patient safety and address the underlying causes of the malpractice problem.
Advances in Patient Safety and Medical Liability presents contributions and findings from several of these projects to illustrate that, despite the complexity of this work, this initiative has contributed important insights to guide future research. In addition to a prologue, the volume includes two commentaries and nine papers, organized into two primary themes: improving communication and improving patient safety. Topics include the role of the patient and family in supporting improved care and patient safety; shared decision-making initiatives; the use of reporting systems; the harmful impact of institutional silence when patient harm occurs; implementation of disclosure, apology, and offer programs; safety culture and disclosure culture surveys; medication safety initiatives; and more.
Many of the activities and findings from the PSML initiative will serve as the groundwork for future patient safety and medical liability projects, as these grants sustained successful implementation and maintenance of their interventions. The papers presented in this volume offer new insights, raise new questions, and identify new areas for further exploration. We hope that this contribution to the field will more firmly establish the importance of emerging research in patient safety and medical liability.
Sharon B. Arnold, PhD
Agency for Healthcare Research and Quality