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Improved Patient Safety

AHRQ Update


Marge Keyes, Center for Quality Improvement and Patient Safety (CQuIPS), Agency for Healthcare Research and Quality (AHRQ).

Denise Remus, Ph.D., R.N., Center for Delivery, Organization, and Markets (CDOM), Agency for Healthcare Research and Quality.

Lucy Savitz, Ph.D., Assistant Professor of Health Policy and Administration and Senior Health Research Analyst, Research Triangle Institute-University of North Carolina, Chapel Hill.

At the national level, AHRQ has spear-headed Federal efforts to expand knowledge about the causes and consequences of medical errors and to develop and test strategies and tools to improve patient safety. Marge Keyes provide an overview of the wide variety of health services research, demonstrations, tool development, information dissemination, and support activities that the Agency sponsors to help reduce medical error and improve patient safety in the United States. Among the specific Agency-sponsored activities highlighted at the workshop were the following:

  • Patient Safety Indicators (PSIs), which are a set of 26 measures designed to help hospital and health care organizations assess, monitor, track and improve the safety of inpatient care. AHRQ's Denise Remus explained that the PSIs can be used at the institutional level for quality improvement purposes and, at the national, State, and regional levels to evaluate potentially preventable complications and identify, evaluate and monitor differences across regions. Community collaborations will find them useful for facilitating the identification and implementation of best practices (
  • Lucy Savitz described an example of the type of patient safety-focused health services research that AHRQ sponsors, a study conducted as part of the Agency's Integrated Delivery System Research Network (IDSRN) initiative examined six information transfer processes across the care continuum and the extent to which they contribute to medication-related errors. The study also examined the extent to which problems in this area might be addressed by information technology (IT) solutions and assessed the extent to which a particular IT intervention reduced the risk of medical errors associated with poor information transfer. Findings from the study indicate that the IT solution reduces the risks associated with poor information transfer in five out of the six process steps and that the risk scores were reduced by half across the six steps.

  • In 2003, AHRQ launched three new patient safety activities/initiatives that provide tools and technical assistance of interest to States, other patient safety organizations, and health care providers:
    • AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is a monthly peer-reviewed Web-based journal that showcases patient safety lessons drawn from actual cases of medical error. It was developed to educate health providers about medical errors in a blame-free environment (
    • Safe Practices Implementation Challenge Grants were established to assess patient safety risks and devise ways to prevent them, as well as to implement safe practices that show evidence of eliminating or reducing known hazards to patient safety. Thirteen projects were funded in 2003 (
    • The Patient Safety Improvement Corps, co-sponsored by AHRQ and the Department of Veterans Affairs, seeks to improve patient safety by bringing teams of State field staff and hospital partners together to receive education and training on the concepts, tools, and skills critical to improving patient safety (

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