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Evidence Reports All of EHC



Summary of Findings on Year 1 Topics

White Paper May 31, 2024
Download the file for this report here.

The fourth installment of the Making Healthcare Safer (MHS) series of reviews marks nearly a quarter century’s progress in efforts to meet the challenge of reducing and, ultimately, eliminating preventable patient harm. Throughout this patient safety journey, the MHS series synthesizes and disseminates evidence on the effectiveness of patient safety practices (PSPs).

For this project, we define PSPs as interventions, strategies, or approaches intended to prevent or mitigate unintended consequences of the delivery of health care and to improve the safety of health care for patients.1 The MHS series guides the field about what works and where more research is needed. The science and practice of patient safety improvement has evolved in the last 20 years and, while certain areas2-6 have realized improvements, health care continues to struggle with improvement rates that are much lower than desired. A recent report from the National Academies of Sciences, Engineering, and Medicine goes as far as to claim that “the country is at a relative standstill in patient safety progress,”7 a claim supported by a recent meta-analysis indicating that as many as 1 in 20 patients continue to experience preventable harm.8 According to a report from the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services, 25 percent of Medicare patients experience harm, with 43 percent of those harm events judged to be preventable.9 The leading types of harm found in the OIG report (i.e., medication errors, pressure ulcers, surgical procedural errors, and infections) align with the topics in the initial MHS report issued more than 20 years ago. Additionally, the coronavirus disease 2019 (COVID-19) pandemic has eroded some of the hard-won gains in reducing preventable harm, such as central line-associated blood stream infections (CLABSIs).10 The current state of the patient safety movement heightens the importance of this fourth installment of MHS as an opportunity to renew focus on foundational elements of safe patient care and move the field forward.

In the spring of 2023, the Agency for Healthcare Research and Quality (AHRQ) launched its fourth iteration of the MHS Report (MHS IV). Thirteen topics were prioritized for inclusion in the MHS IV series based on a modified Delphi technique used by a Technical Expert Panel (TEP) that met in December 2022. The TEP included 15 experts in patient safety, with representatives of important stakeholders and perspectives, including governmental agencies (Centers for Disease Control and Prevention, Defense Health Agency, Department of Veterans Affairs, and Food and Drug Administration), health care stakeholders (Leapfrog Group and UnitedHealth Group), clinical specialists (critical care, hospital medicine, nursing, pharmacy, primary care, and surgery), experts in patient safety issues (health equity, information systems, quality improvement, and social science), and a patient/consumer perspective (Informed Patient Institute). The MHS IV Prioritization Report provides further details about how the TEP was engaged in prioritizing topics for inclusion in MHS IV.11

The MHS IV series consists of two rapid evidence product types (i.e., rapid reviews and rapid responses) to accommodate providing multiple evidence summaries within a two-year period. The type was determined by considering the preliminary body of evidence. Investigators made strategic choices about which processes to abridge to yield the most relevant search results within the topic scope. However, the adaptations made for expediency may limit the certainty and generalizability of the findings from the review, particularly in areas with a large literature base. In the first year of this project, a total of seven rapid reviews and six rapid responses were completed:

Rapid reviews (which are streamlined systematic reviews):

  • Computerized clinical decision support to prevent medication errors and adverse drug events
  • Healthcare worker implicit bias training and education
  • Engaging family caregivers with structured communication for safe care transitions
  • Opioid stewardship
  • Patient safety practices focused on sepsis prediction and recognition
  • Prevention in adults of transmission of infection with multidrug-resistant organisms
  • Failure to rescue - Rapid response systems

Rapid responses (which are brief narrative reviews):

  • Fatigue and sleepiness of clinicians due to hours of service
  • Reducing adverse drug events related to anticoagulant use in adults
  • Use of report cards and outcome measurements to improve the safety of surgical care
  • Deprescribing to reduce medication harms in older adults
  • Patient and family engagement
  • Active surveillance culturing of Clostridiodes difficile and multidrug-resistant organisms, methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacterales (CRE), and Candida auris

In the first year of this project, we also performed a rapid review to assess the evidence on harms associated with patient-clinician real-time clinical encounters using telehealth and to determine the effectiveness of any related PSPs.12 We did not find evidence on the effectiveness of any such PSPs, so that topic was not included with those presented to the TEP.

In addition to considering the TEP’s guidance on the prioritization of topics for inclusion in MHS IV, we reviewed the list of PSPs that were encouraged or strongly encouraged by the TEP that contributed to the MHS II report (as listed in Table 1). Those PSPs have been widely implemented since then. We also reviewed the list of topics covered in the MHS III report, but that report did not specifically make recommendations about which PSPs should be encouraged.

Table 1. List of patient safety practices encouraged by Making Healthcare Safer II

Strongly EncouragedEncouraged
  • Preoperative and anesthesia checklists to prevent operative and post-operative events
  • Bundles, including checklists to prevent central line-associated bloodstream infections
  • Interventions to reduce urinary catheter use
  • Bundles with head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning tubes to prevent ventilator-associated pneumonia
  • Hand hygiene
  • “Do Not Use” list for hazardous abbreviations
  • Multicomponent interventions to reduce pressure ulcers
  • Barrier precautions to prevent healthcare-associated infections
  • Use of real-time ultrasound for central line placement
  • Interventions to improve prophylaxis for venous thromboembolism
  • Multicomponent interventions to reduce falls
  • Use of clinical pharmacists to reduce adverse drug events
  • Documentation of patient preferences for life-sustaining treatment
  • Obtaining informed consent to improve patients’ understanding of potential risks of procedures
  • Team training
  • Medication reconciliation
  • Practices to reduce radiation exposure from fluoroscopy & computed tomography
  • Use of surgical outcome measurements & report cards
  • Rapid response systems
  • Utilization of complementary methods for detecting adverse events/medical errors to monitor for patient safety problems
  • Computerized provider order entry
  • Use of simulation exercises in patient safety efforts

This report provides a summary of the TEP’s judgements about which PSPs are ready for widespread implementation and their rationale based on findings from the rapid reviews and rapid responses completed in the first year of MHS IV.

  1. Agency for Health Care Research and Quality. Assessing the Evidence Base for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria. Solicitation Number: AHRQ-2009–10001. https://www.fbo.gov (accessed Sep 2010).
  2. Bates DW, Singh H. Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Aff. 2018 Nov;37(11):1736-43. DOI: https://doi.org/10.1377/hlthaff.2018.0738. PMID: 30395508.
  3. Clancy CM. Ten years after to err is human. American J Med Qual. 2009 Nov-Dec;24(6):525-8. Epub 2009 Oct 13. DOI: https://doi.org/10.1177/1062860609349728. PMID: 19826077.
  4. Dzau VJ, Shine KI. Two Decades Since To Err Is Human: Progress, but Still a “Chasm.” JAMA. 2020 Dec 22;324(24):2489-90. https://doi.org/10.1001/jama.202023151. PMID: 33351025.
  5. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005 May 18;293(19):2384-90. https://doi.org/10.1001/jama.293.19.2384. PMID: 15900009.
  6. Wachter RM. The end of the beginning: patient safety five years after ‘To Err Is Human’ amid signs of progress, there is still a long way to go. Health Aff. 2004 Jul-Dec;23(Suppl1):W4-534-45. https://doi.org/10.1377/hlthaff.w4.534. PMID: 15572380.
  7. Tang PC, Kearney M, eds. Peer Review of a Report on Strategies To Improve Patient Safety. National Academies of Science, Engineering, and Medicine. 2021. DOI: https://doi.org/10.17226/26136.
  8. Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019 Jul 17;366:l4185. doi: 10.1136/bmj.l4185. PMID: 31315828.
  9. Grimm, CA. Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. U.S. Department of Health and Human Services Office of Inspector General. May 2022. https://oig.hhs.gov/oei/reports/OEI-06-18-00400.pdf.
  10. Patel PR, Weiner-Lastinger LM, Dudeck MA, et al. Impact of COVID-19 pandemic on central-line–associated bloodstream infections during the early months of 2020, National Healthcare Safety Network. Infect Control Hospital Epidemiol. 2022 Jun;43(6):790-3. Epub 2021 Mar 15. doi: 10.1017/ice.2021.108. PMID: 33719981.
  11. Rosen M, Dy SM, Stewart CM, Shekelle P, Tsou A, Treadwell J, Sharma R, Zhang A, Vass M, Motala A, Bass EB. Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV. (Prepared by the Johns Hopkins, ECRI, and Southern California Evidence-based Practice Centers under Contract No. 75Q80120D00003). AHRQ Publication No. 23-EHC019-1. Rockville, MD: Agency for Healthcare Research and Quality. July 2023. DOI: https://doi.org/10.23970/AHRQEPC_MHS4PRIORITIZATION.
  12. Rosen M, Stewart CM, Kharrazi H, Sharma R, Vass M, Zhang A, Bass EB. Potential Harms Resulting From Patient-Clinician Real-Time Clinical Encounters Using Video-based Telehealth: A Rapid Evidence Review (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.). AHRQ Publication No. 23-EHC019-2. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. DOI: https://doi.org/10.23970/AHRQEPC_MHS4TELEHEALTH.

Bass EB, Shekelle P, Treadwell J, Rosen M, Mull NK, Stewart CM, Motala A, Zhang A, Sharma, R. Making Healthcare Safer IV—Summary of Findings on Year 1 Topics. (Prepared by the Johns Hopkins, ECRI-Penn, and Southern California Evidence-based Practice Centers under Contract No. 75Q80120D00003). AHRQ Publication No. 23(24)-EHC019-15. Rockville, MD: Agency for Healthcare Research and Quality. May 2024. DOI: https://doi.org/10.23970/AHRQEPC_MHS4YEAR1. Posted final reports are located on the Effective Health Care Program search page.

Page last reviewed May 2024
Page originally created May 2024

Internet Citation: White Paper: Summary of Findings on Year 1 Topics. Content last reviewed May 2024. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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