Laurie Barclay, MD http://bit.ly/10bJTwc
The Agency for Healthcare Research and Quality (AHRQ) has identified the top 10 patient safety strategies (PSSs) ready for immediate use. Paul G. Shekelle, MD, PhD, from the RAND Corporation, Santa Monica, California, and colleagues present the list in a special supplement to the Annals of Internal Medicine published online March 4. These interventions, if widely implemented, could dramatically enhance patient safety and save lives by reducing medication errors, bed sores, and healthcare-associated infections.
“Wide-scale reductions in patient harm have been modest despite over a decade of research, improvement, and effort since the Institute of Medicine’s ‘To Err is Human’ report,” Patrick W. Brady, MD, told Medscape Medical News in an email interview. “Since that report, the evidence base for safety strategies has continued to grow, but great challenges exist in taking these strategies to scale throughout health systems,” said Dr. Brady, an assistant professor in the Division of Hospital Medicine and the James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, University of Cincinnati, Ohio, who was not involved in the AHRQ project.
According to a journal news release, diagnostic errors result in between 44,000 and 80,000 annual deaths in the United States alone, and bed sores lead to another 68,000 deaths. Thousands more patients die each year as a result of communication errors or failure to receive evidence-based interventions.
During the last 4 years, Dr. Shekelle and colleagues conducted an evidence based assessment of PSSs, including 79 strategies identified in the 2001 AHRQ report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. On the basis of that assessment and subsequent input from clinicians, researchers, and policymakers regarding the epidemiology of errors and preventable harms, the investigators identified the top 10 PSSs, as well as 31 additional PSSs.
“The team of patient safety experts who put this list together are among the most respected safety experts in the world,” Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, told Medscape Medical News in an email interview. “The strategies they have identified are effective, important, and should be on the top of every healthcare leader’s list for consideration.”
AHRQ’s Top 10 Patient Safety Strategies
- preoperative and anesthesia checklists to reduce operative and postoperative events;
- bundles including checklists to reduce septicemia associated with central lines;
- catheter reminders, stop orders, nurse-initiated removal protocols, and other interventions to limit urinary catheter use;
- bundles to prevent ventilator-associated pneumonia, including head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes;
- hand hygiene;
- do-not-use list for hazardous abbreviations;
- multicomponent interventions to help prevent pressure ulcers;
- barrier precautions to reduce healthcare-associated infections;
- central line placement guided by real-time ultrasonography; and
- strategies to improve venous thromboembolism prophylaxis.
“It is as important for hospital and health system leaders to know why some strategies are not on the list as to know what is on the list,” Foster said, wondering about the absence from the list of adoption of electronic health records despite robust decision support. “Is the evidence still emerging? Were they concerned about emerging evidence of some of the risks from use of [electronic health records]?”
Dr. Brady largely agreed with the list but noted that it could be the “source of some spirited debate.” He commended AHRQ for recommending strategies supported by excellent systematic review and/or research designs including randomized trials and comparative effectiveness studies.
“The considerations used by the authors [regarding] scope of problem addressed, strength of evidence of strategy effectiveness, potential for unintended consequences, cost, and difficulty of implementation are logical and will advance the field of patient safety science,” Dr. Brady said.
Implications for Patient Safety
Foster identified 3 challenges to finding the underlying causes of medical errors and strategies for reducing them: budget cuts affecting AHRQ research, rarity of some errors hindering determination of causes and solutions, and multiple causes underlying some errors, which necessitate use of bundled strategies.
“Medical errors are a worldwide problem that can affect many, many patients and their families, and the AHRQ has safety research as one of its missions, but its entire budget is miniscule compared to that of [the National Institutes of Health], and within AHRQ, patient safety is…only one of the important components,” Foster said. “If we want to resolve the problem, we need a sustained and significant investment in patient safety research, which would mean increasing AHRQ’s budget even in this era of federal budget cuts.”
The payoff could be dramatic. The American Hospital Association recently reported that their Hospital Engagement Network of nearly 1600 hospitals had a 40% reduction in central line bloodstream infections using the bundle recommended by AHRQ, and preliminary results on the implementation of the catheter-associated bloodstream prevention bundle appear to be equally promising.
“Wide implementation of [AHRQ’s] strategies would save tens of thousands of lives each year,” Dr. Brady said.
Barriers to improving patient safety may include failure of health systems to implement complex, behavior-based interventions, as influenced by organizational leadership and culture. Dr. Brady recommends additional research in this area.
“An additional challenge to the successful implementation of safety strategies at individual hospitals may be the increasingly long list of ideas to improve patient safety,” Dr. Brady noted. “As this field has no shortage of good ideas, it may be challenging for hospital boards and patient safety leaders to determine where to focus. This rigorously developed, evidence-based top 10 is an important step to help healthcare administrators, clinicians, and researchers best target their efforts to improve patient safety now.”
“Fundamentally, we need to know more about what causes harm to patients and which strategies are effective in preventing them,” Foster concluded.
The AHRQ supported development of their report. Dr. Brady and Foster have disclosed no relevant financial relationships. Some of the report and editorial authors have disclosures involving the National Institutes of Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and the Black Country; ECRI Institute; Veterans Affairs; AHRQ; Centers for Medicare & Medicaid Services; National Institute of Nursing Research, Office of the National Coordinator; UpToDate; Cantel Medical Group; Association for Professionals in Infection Control and Epidemiology, Hospitals and Health Care Systems; National Institutes of Health; Leigh Bureau; Penguin Group; American Board of Internal Medicine, Salem Hospital; Lippincott, Williams & Wilkins, McGraw-Hill; QuantiaMD; PatientSafe Solutions, CRISI, EarlySense; John Wiley and Sons; Marc and Lynne Benioff; United States–United Kingdom Fulbright Commission; RAND Corporation; and/or more than 100 other healthcare organizations including hospitals, healthcare systems, and state medical and hospital associations. Full conflict-of-interest information is available on the journal’s Web site.
Annals Intern Med. Published online March 4, 2013.