… researched this phenomenon, was interviewed by AHRQ WebM&M in 2011. …

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.

This study demonstrated that hospitals participating in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) had significant improvements in adoption and implementation of evidence-based patient safety practices. However, there were no differences in health care–associated infection rates compared with non-CHAIPI hospitals.

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.

The authors advocate that systems thinking needs to be applied more robustly in health care in order to achieve lasting safety improvements.

The implementation of an electronic health record at a Swedish hospital is analyzed through structured interviews, to determine the factors that predicted implementation success.

This article discusses the importance of integrating clinical evidence into routine practice and how such management can improve safety.

The authors surveyed primary care medical groups and found that only 27% have electronic order entry with decision support for chronic disease care. External quality incentives were associated with driving adoption of such tools.

This AHRQ-funded study describes the association between dimensions of effective quality improvement (QI) and their impact on hospital-based patient safety indicators (PSI). Investigators combined data from a national survey of hospital QI practices with four PSIs in demonstrating that physician involvement in QI was the only significant association with improved indicator scores. Involvement of senior management and multiple hospital units in a QI effort failed to demonstrate a significant association with PSI values. This study expands on previous efforts at understanding the organizational factors involved in achieving patient safety improvement.

The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.