Patients requiring intensive care are particularly vulnerable to preventable adverse events, including health care–associated infections. This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients requiring mechanical ventilation in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the Comprehensive Unit-based Safety Program, focusing on implementing evidence-based safety processes by explicitly addressing barriers to improvement and engaging in regular data audit and feedback. Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including ventilator-associated pneumonia) over the study period. Although the study is limited by lack of a concurrent control group, the results indicate the power of collaborative efforts to drive large-scale improvement.

In 2011, the World Health Organization (WHO) created a multi-professional patient safety curriculum guide for training health professionals across the world. This study describes the results of field testing of this curriculum in 12 participating schools across the 6 WHO regions. The guide was well liked by participants and stakeholders and was associated with improvements in student attitudes regarding patient safety. Student knowledge also improved significantly, but overall scores were still quite poor (20.8% correct answers on the post-test versus 10.7% on the pre-test).

Progress in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor understanding of how context influences safety strategies, and insufficient information on how best to implement evidence-based safety strategies. The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, which culminated in the release of the Making Health Care Safer II report. Detailing methodology that the report's authors used to systematically review the evidence on effectiveness, context, and implementation for 41 key safety strategies, this commentary presents 10 strategies considered ready for widespread implementation. These strategies—including checklists to prevent certain health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered to have strong evidence of effectiveness, minimal potential for adverse consequences, and be reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal Medicine.

It is generally agreed that approximately 1 in 10 hospitalized patients experiences an adverse event, and recent research has also quantified the daily risk of preventable adverse events for a typical hospitalization. The phenomenon of cascade iatrogenesis—a single patient suffering multiple adverse events—is well known to clinicians, and this study sought to quantify the incidence of this phenomenon. Using the AHRQ Patient Safety Indicators as a screening tool, the authors found that multiple patient safety events occurred in approximately 1 in 1000 adult hospitalizations. Although these instances were rare, patients with multiple adverse events had prolonged hospitalizations and significantly increased costs compared with uncomplicated hospital stays.

All hospitals are required to maintain a voluntary error reporting system, and such systems serve an important role in detecting safety problems. However, prior research has extensively documented the limitations of such systems. The success of a reporting system rests on four key components, including a supportive safety culture and an effective mechanism for acting on reported issues. This AHRQ-funded survey of risk managers found that most hospitals' systems did not meet these effectiveness criteria, although some improvement had taken place between 2005 and 2009. Proposals for improving the utility of error reporting systems are advanced in a recent AHRQ WebM&M perspective and interview.

This commentary discusses liabilities associated with clinical decision support systems and describes how to improve them and reduce patient harm.

Research on patient safety has dramatically increased in the past decade, but despite this, the progress of improving safety remains slow. Significant controversy exists about how safety interventions should be evaluated, and even apparently successful interventions may not be generalizable to all settings. This AHRQ-sponsored consensus statement by leaders in the safety field defines a framework for rigorous assessment of safety interventions. This framework calls for investigators to use change theory to develop their projects; provide adequate details of the intervention, implementation process, and the context in which the intervention was conducted; and evaluate both the expected outcomes and potential unintended consequences of the intervention. The accompanying editorial (see link below) discusses the challenges of conducting research in complex settings, and takes note of existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.

This study sought to identify which of the AHRQ Patient Safety Indicators (PSIs) could be used as a single measure to screen for patient safety problems. The PSI "selected infections due to medical care" (a measure of health care–associated infections) appeared to be the best single measure for this indication.