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AHRQ and DOD release compendium of patient safety studies showing accomplishments and challenges that lie ahead

The Agency for Healthcare Research and Quality and the U.S. Department of Defense have 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, and discusses the effects of change on dynamic systems of care and national and regulatory issues.

Each of the 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.

Volume 1, 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 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. 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. 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. 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.

Advances in Patient Safety: From Research to Implementation is available from the AHRQ Publications Clearinghouse as a searchable CD-ROM (AHRQ Publication No. 05-0021-CD). A limited number of four-volume printed sets (AHRQ Publication No. 05-0021) are also available from the AHRQ Publications Clearinghouse. Individual articles from the four volumes are available online at

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