As the patient safety evidence base matures, the focus is shifting from effectiveness (identifying which strategies can prevent errors) to implementation (ensuring that all patients receive effective strategies). Pressure ulcers are considered a never event, but their incidence has been increasing despite effective preventive strategies. This systematic review identifies several promising methods of implementing multicomponent interventions to prevent pressure ulcers and emphasizes the importance of leadership, simplification and standardization of safety strategies, and regular audit and feedback of pressure ulcer rates in ensuring intervention success. This study was funded by the Agency for Healthcare Research and Quality as part of the Making Health Care Safer II report and was published as part of a special patient safety supplement in the Annals of Internal Medicine.

… a missed delirium diagnosis are discussed in an AHRQ WebM&M commentary . …

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.