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. 

The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative highlights Save Lives: Clean Your Hands, an annual promotional campaign that takes place on May 5. The theme for 2023 is "Accelerate action together".

Patients, families, and providers around the world are affected by medical error. This annual event and its associated materials seek to raise awareness, motivate collaboration, and stimulate innovative work targeting a distinct patient safety theme. The 2023 theme is “Engaging Patients for Patient Safety" with the slogan “Elevate the voice of patients!” Explicit objectives of the effort include increasing awareness worldwide of the importance of active patient and family engagement in safe care and policy maker advocacy for robust patients and families roles in safety efforts.

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. This project will support the implementation of targeted hospital-acquired infection prevention initiatives building on the Comprehensive Unit-based Safety Program (CUSP) concept. The cohort that is focused on long-term care is currently recruiting participants. 

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Community Pharmacy Survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.

COVID-19 generated unprecedented challenges for the nursing home industry, revealing and amplifying process, staffing, trust, and infection control weaknesses to the detriment of care. This report analyzed current infection protection actions in long-term care. A primary improvement conclusion drawn from the examination is to strengthen the role of infection control professionals.