The application of evidence in real situations helps to embed innovation across systems and sustain care improvement. This collection of project highlight reports shares descriptions of implementation projects and research funded by AHRQ. Topics covered include patient engagement, health information technology, and healthcare facility design.

Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who experienced a fall such as nonslip wear, bed height and visible risk identification. Data for the analysis includes reports on patient safety concerns submitted from 2009 through 2021.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. 

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.