AHRQ releases Making Health Care Safer II report

The Agency for Healthcare Research and Quality (AHRQ) has released a new report, Making Health Care Safer II, which identifies the top 10, evidence-based patient safety strategies available to clinicians.

Principal investigators of the new work are Robert M. Wachter, MD, professor and associate chairman of the UCSF Department of Medicine and chief, UCSF Division of Hospital Medicine; Paul Shekelle of RAND; and Peter Pronovost, MD, of Johns Hopkins University.

The report is a follow up to the landmark 2011 evidence report "Making Health Care Safer: A Critical Analysis of Patient Safety Practices" - the first attempt to apply evidence to the field of patient safety. UCSF faculty helped lead the team that produced that report. The new report, being published in a special supplement of the Annals of Internal Medicine, represents the state of the evidence now.

"This report illustrates that we have made substantial progress in certain areas, such as preventing falls, central line infections, and surgical complications, and that we have a far better understanding of the role of context and implementation," said Wachter. "But it also demonstrates that we still have a long way to go before we can declare victory in the battle to keep patients safe."

UCSF faculty also contributed research papers to the update, which shows that significant progress has been made in patient safety research, now making it possible to know what strategies work, and to provide clinicians and hospitals with a sound basis for integrating proven strategies into their day-to-day delivery of patient care.

The 10 strategies, if widely implemented, have the potential to vastly improve patient safety and save lives in U.S. health care institutions, the report says, by helping prevent harmful events such as medication errors, bed sores, and health care-associated infections.

Ten of the 41 strategies were published today as papers in a special supplement to Annals of Internal Medicine, available at http://www.annals.org/issue.aspx?journalid=90&issueid=926462.

The entire report, including evidence reviews for all 41 patient safety strategies, can be found at http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

The 2001 AHRQ report helped identify early evidence-based safety practices and opportunities for research. It was immediately preceded by two major Institute of Medicine reports, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm, which together galvanized the modern patient safety and quality improvement movements in the United States.

The 10 strongly recommended patient safety strategies ready for adoption now are:

1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events
2. Bundles that include checklists to prevent central line-associated bloodstream infections
3. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia
4. Hand hygiene
5. The do-not-use list for hazardous abbreviations
6. Multicomponent interventions to reduce pressure ulcers
7. Barrier precautions to prevent health care-associated infection
8. Use of real-time ultrasonography for central line placement
9. Interventions to improve prophylaxis for venous thromboembolisms
10. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols