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AHRQ has just released “Strategies to Improve Patient Safety” (AHRQ 2021). This is the final report required by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). We really have mixed feelings about this report.
Perhaps the biggest disappointment we have has to do with PSO’s (Patient Safety Organizations). When these were originally created, we had great expectations that the work of PSO’s would result in dissemination of innumerable lessons learned from analysis of root causes from many sources. But where are those lessons learned! Some obviously would have been shared among members of the individual PSO’s (the confidentiality and privilege protections afforded by the Patient Safety Act only apply when a provider works with a federally listed PSO), but there has been no public release of lessons learned to the greater healthcare community.
To date, PSOs have voluntarily submitted over 2 million records to the NPSD (Network of Patient Safety Databases), which is the data infrastructure aspect of the Patient Safety Act. However, the NPSD’s ability to publicly release data is constrained by limitations in the mechanisms currently available for data collection and the need to accumulate a sufficient volume of data prior to public release in order to protect confidentiality. The report also notes that the voluntary nature of the system and corresponding need to minimize the burden of data submission affects the nature, volume, and quality of the data available to the NPSD
The NPSD needed a critical mass of data before it could become operational. The NPSD achieved this threshold and launched in June 2019. The NPSD has provided various dashboards, but these largely only provide us with a snapshot of the various types and frequency of incidents. Dashboards utilize AHRQ’s Common Formats, Common Formats for Event Reporting (CFER), and Common Formats for Surveillance (CF-S).
The report does list in tabular form strategies and practices to reduce errors. It provides these in 28 categories, providing links to the evidence base for each. Those links come primarily from three “Making Health Care Safer” books (Shojania 2001, AHRQ 2013, Hall 2020).
The report goes on to describe the CUSP (Comprehensive-Unit-based-Safety-Program) program, which we have discussed in multiple columns as being a major reason for success of such collaboratives as the Michigan Keystone Project. It also describes TeamSTEPPS®, which we’ve also discussed in many columns.
The report discusses various other AHRQ grant-supported research projects and learning initiatives, the AHRQ patient safety primers and toolkits, and the CANDOR (Communication and Optimal Resolution) process
And it discusses “Safer Together: A National Action Plan to
Advance Patient Safety” (IHI
2020) put together by the National Steering Committee for Patient Safety
and lists the 17 recommendations to advance patient safety from that action
AHRQ. Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.
AHRQ. NPSD Dashboards.
Shojania KG, Duncan BW, McDonald KM, et al., editors. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Reports/Technology Assessments, No. 43. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Jul.
AHRQ. Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Reports/Technology Assessments, No. 211; Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Mar.
Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); Report No.: 20-0029-EF; 2020 Mar.
National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement. 2020
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