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Evidence-based Tips from AHRQ Help Hospitals Promote Patient Safety

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Press Release Date: November 16, 2006

Practical tips for promoting a culture of patient safety, limiting shifts for medical residents and interns, and adopting interventions to reduce cases of ventilator-associated pneumonia and catheter-related urinary tract infections are among the evidence-based research findings that the Department of Health & Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) has compiled to help hospitals provide the highest quality care possible. A new tipsheet, 10 Patient Safety Tips for Hospitals, was unveiled by AHRQ Director Carolyn M. Clancy, M.D., today at the Joint Commission on Accreditation of Healthcare Organizations' annual patient safety conference in Chicago.

"The care provided in hospitals every day is more prone to errors than other health settings because of the multiple people, processes, and transitions in care delivery," said AHRQ's Dr. Clancy. "While many hospitals have made significant progress toward reducing the likelihood of patient harm associated with the delivery of health care, most continue to look for ways to promote patient safety on a day-to-day basis, and we hope these simple tips will help them do that."

The tips cover a range of activities including how to reduce the likelihood of fatigue-related mistakes, ensuring safety in intensive care units (ICUs), using technology to improve clinical care, and more. Each tip provides a brief synopsis of key data or findings from AHRQ-supported research to help organizations recognize the benefit of changing their current practices. AHRQ is also working with hospitals, nurses, medical residency program directors, and others to disseminate these findings.

As an example, AHRQ-funded research has found that the rate of serious medical errors at two Boston hospital ICUs dropped 36 percent when 30-hour-in-a-row work shifts for first-year residents were eliminated. Based on these findings, hospitals should eliminate the tradition of shifts of more than 30 consecutive hours by interns working in ICUs, the tipsheet advises. In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to no more than 80 hours per week.

Also, hospitals could use computer-based order entry systems to reduce catheter-related urinary tract infections. This evidence is based on AHRQ research that found that systems that prompted catheter removal after 72 hours decreased the duration of urinary catheterization and incidence of urinary tract infections. AHRQ hopes the tipsheets will be posted in hospitals nationwide.

The one-page tipsheet is available on the AHRQ Web site at Single copies may be obtained from the AHRQ Publications Clearinghouse by sending an E-mail to or calling 1-800-358-9295.

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


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