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Patient Safety and Quality

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Health systems dedicated to improving patient safety are beginning their journey and need a roadmap to prioritize initiatives

As part of its mission to close the gap between evidence-based research findings and their implementation, the Agency for Healthcare Research and Quality (AHRQ) supported a customer service survey to determine how eight health system leaders, known for their dedication to improving patient safety, were seeking to reduce medical errors. Specifically, the survey sought to answer the question of whether an overall error reduction framework, such as high reliability organizing (HRO), was being used and to determine how the Agency could work with these and similar leaders to improve patient safety.

HRO is typically found in industries—such as airlines and nuclear power—that experience fewer than expected errors because they take a certain approach to maintain a culture of safety. While this framework has been used outside of health care for a number of years, its use in health care systems is relatively recent.

Interview results found that health system leaders saw themselves as being at the beginning of their patient safety journey, and used the words "struggling" quite a bit to describe how they were thinking through patient safety issues and initiatives. They often turned to outside industries for ways to improve practice because those industries had been involved in quality improvement for some time. However, they were eager to learn from others in health care as to how best to transform care in their organizations.

While not all were familiar with HRO, most stated that cultivating a culture of safety was an essential ingredient for medical error reduction. For example, health care systems were implementing culture initiatives such as patient safety surveys, executive walk-arounds, and safety audits. Focusing on a culture of safety was only one of four areas in which these systems are implementing changes. The others included technology-related projects such as computerized physician order entry and electronic medical records; microsystem initiatives such as surgical site infection, injuries from falls, and pressure ulcers; and system/staffing changes such as unit-based pharmacies, integrated teams, and rapid-response teams. Some of the larger organizations had as many as 15 separate initiatives taking place at any time.

A number of leaders expressed concern about the lack of a clear roadmap on how to phase in patient safety initiatives and the order in which to implement them. That included knowing which clinical conditions to address first and which clinical areas would provide the largest impact for dollars spent.

The insights gained from this customer needs assessment led AHRQ to build a learning network among leading edge healthcare systems. It is anticipated that this network, through the use of evidence-based research and shared learning, will support these systems in becoming more reliable.

See "Struggling to invent high-reliability organizations in health care settings: Insights from the field," by Nancy M. Dixon, Ph.D., and Marjorie Shofer, B.S.N., M.B.A., in the August 2006 HSR: Health Services Research 41(4), pp. 1618-1632. Reprints (AHRQ Publication No. 06-R075) are available from the AHRQ Publications Clearinghouse.


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