Agency News and Notes

AHRQ releases new evidence on proven patient safety practices

The Agency for Healthcare Research and Quality has released a new evidence report on practices that could improve patient safety throughout the Nation's health care system. The evidence report, compiled by AHRQ's Evidence-based Practice Center at the University of California, San Francisco/Stanford University, reviews the evidence on a total of 79 patient safety practices. It lists 73 practices that are likely to improve patient safety and describes 11 others that the researchers considered highly proven to work but not performed routinely in the Nation's hospitals and nursing homes.

The report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, is the result of a comprehensive review of the literature from medicine, aviation, and other relevant fields. Among the 11 highly proven practices are giving patients antibiotics just before surgery to prevent infections, using ultrasound to help guide the insertion of central intravenous lines and prevent punctured arteries and other complications, and giving surgery patients beta blockers to prevent heart attacks during or after surgery. Some practices are not included because they lack sufficient testing to be considered highly proven or they carry important potential risks. These include the increasing use of antibiotics to prevent infections, which may lead to antibiotic resistance.

The report also is being provided to members of the National Forum for Health Care Quality Measurement and Reporting (NQF), which includes consumers, public and private purchasers, employers, health care providers, accrediting bodies, and organizations involved in health care research or quality improvement. The NQF plans to use this information to develop a list of measures that patients throughout the Nation can use to determine the actions that hospitals and/or health care facilities have taken to improve safety.

To compile the 640-page report, researchers reviewed the medical and other scientific literature on safety practices and consulted with health care experts. They focused on issues relevant to care delivered in hospitals (where the risk of medical errors is significant) and on prevalent diseases and procedures rather than on specific diagnoses. They chose to exclude practices for which little or no scientific evidence could be found to help assess their usefulness, as well as practices that only affect the care of patients with a specific diagnosis.

Researchers were surprised that more than a dozen practices long considered important by patient safety experts—including the use of computerized order entry systems, improved handwashing compliance, and changes in nurse/patient staffing ratios—haven't been sufficiently studied and therefore didn't make the top 11 list.

Select to access both a summary and the full report. Print copies of the summary (AHRQ Publication No. 01-E057) and the full report (AHRQ Publication No. 01-E058) are available from the AHRQ Publications Clearinghouse.

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