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Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality’s Making Healthcare Safer III Report

Shoemaker-Hunt, Sarah PhD, PharmD; Hall, Kendall MD, MS; Hoffman, Lynn MPH, MA

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doi: 10.1097/PTS.0000000000000761
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The Making Healthcare Safer (MHS) reports from the Agency for Healthcare Research and Quality (AHRQ)1–3 have provided reliable information for improving the safety and quality of care for patients since 2001. The reports—providing an analysis of the evidence for various patient safety practices (PSPs)—have served as a consolidated and up-to-date source of information for multiple stakeholders, including healthcare providers, health system administrators, researchers, and government agencies. The reports have also identified contextual factors that contribute to successful PSP implementation and provided information about the unintended consequences of implementing proposed PSPs. As a result, the reports have helped shape national and local actions regarding patient safety issues on which providers, payers, policy makers, and patients and families should focus attention.

Since the second MHS report was published in 2013, there have been many improvements in patient safety, demonstrating that concerted efforts to improve patient safety, such as the AHRQ’s Comprehensive Unit-based Safety Program, can reduce harm to patients and improve quality of care on a large scale.4 In addition, building on the success of PSPs in inpatient settings, AHRQ began a deliberate effort to support a culture of safety across the healthcare continuum, including in nursing homes, home care, outpatient, and ambulatory settings, and during care transitions. The field of patient safety continues to expand, with an increasing number of PSPs being developed, tested, and implemented across the healthcare spectrum at different scales—from single settings of care to large nationwide integrated delivery systems. For example, AHRQ’s Safety Program for Nursing Homes: On-Time Prevention supported national testing of infection prevention and pressure ulcer prevention protocols in nursing homes.5

There has been increasing recognition of the importance of understanding context in successful PSP implementation, creating another factor that must be considered when determining which PSPs are feasible for a particular care setting. The recent Partnership for Patients initiative of the Centers for Medicare & Medicaid Services (CMS) was an example of federal policymaking directly focused on improving patient safety.6 Financial incentives to reduce harms (e.g., the CMS Hospital-Acquired Condition Reduction Program) aim to hold providers financially accountable for patient safety. Changes in healthcare reimbursement that emphasize value over volume can incentivize safety improvements, such as bundled episodes that require care in the right setting at the right time, as well as effective coordination during care transitions. Current trends in the healthcare marketplace can also be leveraged to enhance safety in all care settings, including expanding technologies to evaluate and monitor patients and share information across care settings. The availability of healthcare data has improved and increased, with great promise for continuously improving PSPs. Public reporting is also making quality of care increasingly transparent—for example, via CMS’s Hospital Compare and Nursing Home Compare Web sites.

This evolution of care delivery and the need to take steps to ensure patient safety in all settings necessitated an expanded scope for the most recent MHS report. Other recent federal reports have also spurred this expansion in scope, such as the Department of Health and Human Services Office of the Inspector General adverse event series beginning in 2008, for example, Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.7

For the most recent MHS project (2017–2020), we have worked to move from a review of predominantly acute care PSPs to include PSPs focusing on other settings and other aspects of care, such as transitions. The scope of this work has also expanded to match emerging themes and strategic goals championed by the Department of Health and Human Services, including addressing the opioid crisis and emerging health risks (e.g., multidrug-resistant organisms), and overall directives to “put patients first” and to reduce provider burden and burnout—for example, CMS’s Patients over Paperwork initiative.

The MHS III project team began its work by developing a new conceptual framework that (1) puts the patient in the center; (2) acknowledges that patients are constantly exposed to the risk of harm; and (3) proposes patient safety approaches that mitigate patients’ past and future vulnerabilities.3 We have thus taken an approach that is both holistic (considering the whole patient through the continuum of care) and targeted (focusing on what harms are relevant to a particular patient at a particular point in care). In addition, by following the patient, this framework includes harms during movement between settings and harm risks from existing vulnerabilities and disparities. Starting from the new conceptual framework, we organized the evidence reviews by “harm areas.” This will make the work easier to access for all patient safety stakeholders, who will be able to quickly locate topics of interest and importance to their particular needs and circumstances.

All of the MHS III evidence reviews can be found in the AHRQ “Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices” report.3 The 5 major threats to safety that are addressed in this report include medication-management issues, healthcare-associated infections, nursing-sensitive events, procedural events, and diagnostic errors, and the report covers 47 PSPs in 17 specific harm areas. This supplement presents the reviews for 8 PSPs, representative of the range of the report: (1) The Use of Rapid Response Teams to Reduce Failure-to-Rescue Events; (2) The Use of Patient Monitoring Systems to Improve Sepsis Recognition and Outcomes; (3) Environmental Cleaning and Decontamination to Prevent Clostridioides difficile Infection in Healthcare Settings; (4) Chlorhexidine Bathing Strategies for Multidrug-Resistant Organisms; (5) Using Deprescribing Practices and STOPP Criteria to Reduce Harm and Preventable Adverse Drug Events in Older Adults; (6) The Effect of Opioid Stewardship Interventions on Key Outcomes; (7) System-Level Patient Safety Practices that Aim to Reduce Medication Errors Associated with Infusion Pumps; and (8) Improving Team Performance and Patient Safety On the Job Through Team Training and Performance Support Tools. We encourage all readers to review the full MHS III report.3

REFERENCES

1. Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California at San Francisco–Stanford Evidence-based Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001. Available at: https://archive.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf. Accessed June 17, 2020.
2. Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Available at: https://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html#Report. Accessed June 17, 2020.
3. Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. (Prepared by Abt Associates Inc. under Contract No. 233-2015-00013-I.) AHRQ Publication No. 20-0029-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2020. Available at: https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html. Accessed June 17, 2020.
4. Agency for Healthcare Research and Quality. AHRQ Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014-2017. Rockville, MD: Agency for Healthcare Research and Quality:2019. Available at: https://www.ahrq.gov/hai/pfp/index.html. Accessed June 17, 2020.
5. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html. Accessed June 17, 2020.
6. Centers for Medicare & Medicaid Services. Partnership for Patients. Available at: https://innovation.cms.gov/initiatives/partnership-for-patients/. Accessed January 23, 2020.
7. U.S. Department of Health and Human Services Office of Inspector General. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-14-00110. Washington, DC: U.S. Department of Health and Human Services Office of Inspector General; 2016. Available at: https://oig.hhs.gov/oei/reports/oei-06-14-00110.asp. Accessed June 17, 2020.
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.