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AHRQ's New Advances in Patient Safety: From Research to Implementation Shows Accomplishments, Challenges for Improving Patient Safety and Reducing Medical Errors

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Press Release Date: May 4, 2005

HHS' Agency for Healthcare Research and Quality and the U.S. Department of Defense today released the federal government's first compendium of studies on the successes and challenges of efforts to improve patient safety and reduce medical errors. Advances in Patient Safety: From Research to Implementation is a four-volume set of 140 peer-reviewed articles that represents an overview of patient safety studies by AHRQ-funded researchers and other government-sponsored research.

The four volumes contain information on virtually every dimension of the patient safety field, including new research findings on medication safety, technology, investigative approaches to better treatment, process analyses, human factors, and practical tools for preventing medical errors and harm. The compendium features emerging lessons from clinical studies, presents cutting-edge technologies such as simulation tools for surgery training, the effects of change on dynamic systems of care, and national and regulatory issues.

"Our hope is that the information and knowledge contained in these volumes will fuel the momentum of efforts to improve patient safety," said AHRQ Director Carolyn M. Clancy, M.D. "This new resource should give researchers and practitioners a sense of what has been accomplished and what still needs attention."

Each of the four volumes begins with a commentary from a patient safety expert who addresses questions and topics that range from whether patients are safer today than when the Institute of Medicine highlighted the problem of medical errors in 1999, the merits and challenges of a systems approach to health care safety, the challenges associated with implementing safe practices, and the scope of the programs, tools and products needed to improve safety in a variety of settings, along with their potential barriers to success.

The research presented in Volume 1 "demonstrates solid, broad, and rapid progress" in the field, says Brent C. James, M.D., executive director of Intermountain Health Care's Institute for Health Care Delivery Research in Salt Lake City. This volume, which focuses on research findings, explores strategies central to the delivery of safe and effective care. It includes articles on state-of-the-art detection and tracking systems, interventions that address adverse drug events, building a culture of safety within institutions, the importance of teamwork, safety in different locales, the role of technology, and the role of national- and state-level policy.

Volume 2 covers concepts and methodology and examines complex systems of care used to treat patients. Such considerations are enabling many in health care to "move beyond the old 'name, blame, and shame' approach to improving safety to a more effective focus on human factors engineering and the systems" within which health care professionals work, according to Paul Schyve, M.D., senior vice president at the Joint Commission on Accreditation of Healthcare Organizations in Chicago. This volume presents research examining adverse event classification techniques, caregiver-device interaction issues, system and process analyses, and practice and procedural redesign.

Volume 3 covers implementation issues, identifying both barriers to diffusion of patient safety improvements in health care and approaches for producing cultural change. Despite the challenges, implementation issues are "where it's at for patient safety,"according to commentator Lucian Leape, M.D., a longtime patient safety researcher who is an adjunct professor of Health Policy in the Department of Health Policy and Management at the Harvard School of Public Health in Boston. "Only by putting into practice what we learn in our research will we make care safer," he said. This volume examines health information technology's promises and limitations, interventions for improving patient outcomes, hospital staff consensus building, and reporting reluctance and liability concerns.

Volume 4 showcases programs and products, screening tools and process simulators, communication education initiatives, safety climate and attitude surveys, and improved training models for new providers. Authors also provide details about overcoming barriers to achieve success. The articles reflect the array of health care settings in which safety efforts are underway, from hospitals to nursing homes to outpatient surgery to other community settings. "The authors provide not just the tools, but—in many cases—the equivalent of an instruction manual for assembling, using and ultimately achieving the results the product, tool, or program is designed to achieve," says Mary K. Wakefield, Ph.D., R.N., an associate dean and director at the School of Medicine and Health Sciences at the University of North Dakota.

Advances in Patient Safety: From Research to Implementation is available as a searchable CD-ROM. A limited number of four-volume printed sets also are available. To order free single copies of the CD-ROM or a printed set, contact the AHRQ Publications Clearinghouse at 1-800-358-9295, or at Individual articles that comprise the four volumes are also available at

For more information, please contact AHRQ Public Affairs: (301) 427-1855 or (301) 427-1865.


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