Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the
National Quality Forum
. It also engendered a spirited debate between those who advocated a
to the adoption of safety practices and those promoting a more
. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Free full text (PDF)
AHRQ's Quality Challenge.
Rockville, MD: Agency for Healthcare Research and Quality; April 2005.
Advances in Patient Safety: From Research to Implementation.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
Advances in Patient Safety: New Directions and Alternative Approaches.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
Staggered Sensitivity Results
Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.
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