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Press Release Date: July 17, 2001
The Agency for Healthcare Research and Quality (AHRQ) today released new evidence 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, reviewed the evidence on a total of 79 patient safety practices. It lists 73 that are likely to improve patient safety and describes 11 that the researchers considered highly proven to work but are not performed routinely in the nation's hospitals and nursing homes.
"We are sharing these findings with health care administrators, medical directors, health professionals, and others who are responsible for patient safety programs in the institutions where they work," said HHS Secretary Tommy G. Thompson. "The nation's health care leaders need to know what the science says about where the opportunities exist to make patient care safer right now."
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 the operation. 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 has the potential to create 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 studies could be found to help assess their usefulness as well as practices that only affect the care of patients with a single 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 staffing ratios-haven't been sufficiently studied and therefore didn't make the top 11 list. "Even though many of these practices are clearly valuable in improving patient safety, the report shows that there needs to be more research in these areas so that we know more about which practices are most effective and how complex or costly they would be to put into place," said AHRQ Director John M. Eisenberg, M.D.
AHRQ, the lead federal agency charged with improving the quality and safety of health care services, has funded the bulk of the research conducted to date on medical errors, including the groundbreaking Harvard Medical Practice Study and other research by Lucian Leape. AHRQ will award nearly $50 million over the next few months to support further research on patient safety.
Copies of the full report can be found on AHRQ's Web site at http://www.ahrq.gov/clinic/ptsafety/ or can be obtained by calling the AHRQ Publications Clearinghouse at (800) 358-9295 or sending an E-mail to AHRQPubs@ahrq.hhs.gov.
For more information, please contact Farah Englert, (301) 427-1865 (FEnglert@ahrq.gov).