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Agency for Healthcare Research Quality

AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care

In September 2008, the Agency for Healthcare Research and Quality (AHRQ) awarded $3,708,799 for risk-informed intervention grants. These 3-year projects will support risk-informed development and implementation of safe practice interventions that have the potential of eliminating or reducing medical errors, risks, hazards, and harms associated with the process of care in the ambulatory setting. The objectives of these projects are to:

  1. Identify, develop, test, and implement safe practice interventions in ambulatory care settings.
  2. Share the findings and lessons learned about the challenges and barriers to developing and implementing these interventions through toolkits.


There is limited data on the nature of risks and hazards to patients and threats to quality in the ambulatory care setting, and few ambulatory safe practices have been identified. For this reason, AHRQ funded planning projects in FY 2007 to identify the risks and hazards imbedded in the process and structure of ambulatory care through the funding opportunity entitled Ambulatory Care Patient Safety Proactive Risk Assessment. These planning projects were intended to provide well documented risk assessment reports. For further information on proactive risk assessment and the goals and objectives of the planning projects, please see RFA-HS-07-033 (

The FY 2008 implementation grants described here (based on RFA-HS-08-004, apply what has been learned in these proactive risk assessments to the improvement of safety and quality in ambulatory care through risk-informed design. Risk-informed designs are quality improvement approaches that engineer out, isolate, and/or manage potential and actual risks and hazards. Knowing where the risks and hazards are informs the development of appropriate interventions that can eliminate or minimize these problems. By using proven, proactive risk assessment and modeling methods, AHRQ expects to begin to move the process of ambulatory care to implementing risk-informed safe practice interventions.

Building on those proactive risk assessment projects, this funding opportunity announcement (FOA) is focused on projects that will: (1) demonstrate safe practice intervention strategies that use risk-informed approaches to improve the processes of care and (2) disseminate information about the interventions through publicly available implementation toolkits that can be adapted and/or adopted by other health care organizations. These new projects must use interventions that are intended to eliminate, reduce, and/or mitigate the risks and hazards identified in the grantee's earlier proactive risk assessment project. This FOA provides an opportunity for AHRQ to work with the grantees and their partners to improve the implementation of risk-informed patient safety practices. These partnerships may facilitate opportunities for collaboration and coordinated efforts in response to new, emerging, or ongoing issues related to patient safety.

Projects Descriptions

Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation
Principal Investigator: Michael R. Cohen, Sc.D., R.Ph.
Description: To test and implement focused interventions at community pharmacies to reduce, eliminate, or mitigate the risks and hazards identified in the previously conducted prospective risk assessment of specific medications.
Applicant Institution: Institute for Safe Medication Practices; Horsham, PA
Year 1 Funding: $298,401
Grant No.: HS017901-01

Optimizing Safety in Ambulatory Procedural Care: Risk-informed Interventions
Principal Investigator: Meghan M. Dierks, M.D.
Description: To conduct an implementation to reduce the system pressures that negatively influence provider behavior and create unsafe operating conditions within the domain of ambulatory procedural sedation.
Applicant Institution: Beth Israel Deaconess Medical Center; Boston, MA
Year 1 Funding: $229,674
Grant No.: HS017907-01

A Toolkit for Primary Care Practices to Improve the Safety of Testing Processes
Principal Investigator: Milton Eder, Ph.D.
Description: To develop, test, implement, and disseminate a toolkit for primary care offices and health centers to improve the safety of their testing processes.
Applicant Institution: Access Community Health Network; Chicago, IL
Year 1 Funding: $295,093
Grant No.: HS017911-01

Risk-informed Intervention to Improve Ambulatory Drug Monitoring and Safety
Principal Investigator: Terry S. Field, Sc.D., M.P.H.
Description: To reduce medication errors associated with high-risk medications by improving laboratory monitoring.
Applicant Institution: University of Massachusetts Medical School; Worcester, MA
Year 1 Funding: $287,298
Grant No.: HS017906-01

Safety Advancement in the Emergency Department
Principal Investigator: Kendall K. Hall, M.D.
Description: To develop, implement, and evaluate a tool that will minimize the risks of gaps in care that arise from diagnostic study processes and medication delivery within the emergency department.
Applicant Institution: University of Maryland School of Medicine; Baltimore, MD
Year 1 Funding: $278,410
Grant No.: HS017904-01

Risk-Informed In-Situ Simulations for Pediatric Emergency Transfers
Principal Investigator: Jane L. Holl, M.D., M.P.H.
Description: To integrate specific TeamSTEPPS, knowledge-based skills to address the identified clinician communication, teamwork, and micro-system risks encountered in pediatric emergency transfers via in situ simulation training.
Applicant Institution: Feinberg School of Medicine, Northwestern University; Chicago, IL
Year 1 Funding: $292,250
Grant No.: HS017909-01

A Human Factors Intervention to Reduce Risk in Primary care of the Elderly
Principal Investigator: Ben-Tzion Karsh, Ph.D.
Description: To develop, test, implement, and share an intervention promoting situational awareness of health care professionals in the administration of primary care to elderly patients.
Applicant Institution: University of Wisconsin-Madison; Madison, WI
Year 1 Funding: $292,699
Grant No.: HS017899-01

Improving the Safety of Primary Care by Measuring Adverse Events and Improvement
Principal Investigator: Donald A. Kennerly, M.D., Ph.D.
Description: To develop a dissemination package of training materials and implementation tools for adoption by other organizations that would enable them to effectively use the BHCS/IHI Outpatient Trigger Tool to measure the rate of adverse events in ambulatory settings.
Applicant Institution: Baylor Research Institute; Dallas, TX
Year 1 Funding: $300,334
Grant No.: HS017908-01

Safe Passages: A Toolkit to Ensure Quality Transitions from NICU to Ambulatory Care
Principal Investigator: Virginia A. Moyer, M.D., M.P.H.
Description: To target the high-risk processes previously identified regarding the transition from neonatal intensive care units to outpatient follow-up, and to design and evaluate interventions that have the potential to decrease the risk of errors and adverse events in this transition.
Applicant Institution: Baylor College of Medicine; Houston, TX
Year 1 Funding: $299,764
Grant No.: HS017889-01

Improving Medication Management in Ambulatory Care
Principal Investigator: Wilson D. Pace, M.D.
Description: To implement an evidence-based quality/safety improvement process to address the issue of medication monitoring in ambulatory practices.
Applicant Institution: University of Colorado at Denver Health Sciences Center; Aurora, CO
Year 1 Funding: $293,023
Grant No.: HS017886-01

Process Reliability and Organizational Learning in Home Health Care
Principal Investigator: Michael P. Silver, M.P.H.
Description: To reduce avoidable hospitalizations in the home health setting by developing, implementing, evaluating, and disseminating a risk-informed intervention program.
Applicant Institution: Health Insight; Salt Lake City, UT
Year 1 Funding: $267,812
Grant No.: HS017903-01

Reducing Risks by Engineering Resilience into Health Information Technology
Principal Investigator: Robert L. Wears, M.D.
Description: To develop a toolkit that would enable organizations to identify and rank the safety-criticality of information systems.
Applicant Institution: University of Florida; Jacksonville, FL
Year 1 Funding: $286,623
Grant No: HS017902-01

Risk-informed Clinical Information Network for Safe Pediatric Emergency Transfers
Principal Investigator: Donna M. Woods, Ph.D.
Description: To develop and implement a risk-informed, Web-based clinical information network for safe and reliable clinical communication for pediatric transfers.
Applicant Institution: Feinberg School of Medicine, Northwestern University; Chicago, IL
Year 1 Funding: $287,418
Grant No: HS017912-01

For additional information:

Robert J. Borotkanics, M.P.H.
Program Officer
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Current as of October 2008

Internet Citation:

AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care. October 2008, Agency for Healthcare Research and Quality, Rockville, MD.


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