AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century

AHRQ's three Making Healthcare Safer reports consolidate information for healthcare providers, health system administrators, researchers, and government agencies about practices that can improve patient safety across the healthcare system—from hospitals to primary care practices, long-term care facilities, and other healthcare settings.

Despite sustained national attention and successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries each year. The three reports—including the most recent report released in 2020—provide information the field needs to evaluate how to prioritize efforts to keep patients safe.

The first Making Health Care Safer report, published in 2001, was developed following the 1999 publication of To Err is Human: Building a Safer Health System, the seminal National Academy of Medicine report that elevated awareness of longstanding risks and patient harms occurring in the U.S. healthcare system. The inaugural report consisted of 50 patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse events and associated systemic and contextual factors.

In 2013, AHRQ published a second edition of Making Health Care Safer. That report added new evidence-based safety practices while updating some practices with new evidence, and contained 41 patient safety practices. 

AHRQ's third and most recent Making Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm areas. It includes evidence for more specific harm areas than the preceding reports.

A set of tables compares the patient safety practices among the three reports.