A Critical Analysis of Existing and Emerging Patient Safety Practices
Despite sustained national attention and notable successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, healthcare-associated infections (HAIs), falls, and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries each year. AHRQ statistics (PDF) estimate that in 2017, there were 86 hospital-acquired conditions per 1,000 hospital discharges—a figure that has fallen steadily in recent years but remains alarmingly high.
AHRQ’s Making Healthcare Safer III report addresses this continuing problem by supporting the implementation of patient safety practices where appropriate, advancing a framework for patient safety transformation, and considering the contextual factors that can lead to successful use of patient safety interventions. Making Healthcare Safer III reviews 47 practices that target patient safety improvement in hospitals, primary care practices, long-term care facilities, and other healthcare settings.
The 47 practices are categorized among 17 chapters that represent harm areas including medication management, healthcare-associated infections, nursing-sensitive practices, procedural events, and diagnostic errors. The practices include clinical decision support technologies, use of rapid-response teams, special hygiene and disinfection interventions to prevent HAIs, and several practices designed to prevent medication errors and reduce opioid misuse and overdose.
This is AHRQ’s third Making Healthcare Safer report. The first two reports, published in 2001 and 2013, have each served as a consolidated source of information for healthcare providers, health system administrators, researchers, and government agencies. A set of tables compares the patient safety practices among the three reports.
Diagnostic Errors (PDF, 2.6 MB)
Failure To Rescue (PDF, 1.8 MB)
Sepsis Recognition (PDF, 2.3 MB)
Clostridioides difficile Infection (PDF, 2.4 MB)
Infections Due to Other Multidrug-Resistant Organisms (PDF, 6 MB)
Carbapenem-Resistant Enterobacteriaceae (PDF, 415.4 KB)
Harms Due to Anticoagulants (PDF, 2 MB)
Harms Due to Diabetic Agents (PDF, 1.6 MB)
Reducing Adverse Drug Events in Older Adults (PDF, 415.7 KB)
Harms Due to Opioids (PDF, 2.1 MB)
Patient Identification Errors in the Operating Room (PDF, 1.3 MB)
Infusion Pumps (PDF, 1.6 MB)
Alarm Fatigue (PDF, 1.7 MB)
Delirium (PDF, 1.9 MB)
Care Transitions (PDF, 1.8 MB)
Venous Thromboembolism (PDF, 1.5 MB)
Cross-Cutting Patient Safety Topics/Practices (PDF, 5.4 MB)