A Continuous Updating of Patient Safety Harms and Practices

AHRQ’s prior Making Healthcare Safer reports I (2001), II (2013), and III (2020) have shown the positive impact of patient safety practices on the reduction of medical errors. However, threats to patient safety are still emerging and evolving in a dynamic world.

Patient safety research is growing, spanning across more healthcare settings, and considers a wide array of contextual factors. The combination of emerging patient safety threats and the growing amount of published patient safety research, patient safety resources, and accrediting body standards makes it increasingly difficult to prioritize adoption and implementation of evidence-based practices. AHRQ’s fourth iteration of Making Healthcare Safer intends to address this issue by publishing rapid evidence reports of patient safety practices and topics as they are completed. The timely ongoing release of reports will aid healthcare organization leaders in prioritizing implementation of evidence-based practices in a timelier way. These reports also will help researchers identify where more research is needed and assist policymakers in understanding which patient safety practices have the supporting evidence for promotion.

Making Healthcare Safer IV began with a horizon scan to identify emerging trends and needs in the patient safety field. A technical expert panel prioritized topics and patient safety practices, including updates to previous Making Healthcare Safer report topics, which would be most beneficial to the field if included in Making Healthcare Safer IV. These activities are summarized in the Prioritization Report.

The Making Healthcare Safer IV rapid evidence reports will be linked below as they are released.

• Potential Harms Resulting From Patient- Clinician Real-Time Clinical Encounters Using Video-Based Telehealth
• Patient and Family Engagement
• Use of Report Cards and Outcome Measurements To Improve the Safety of Surgical Care
• Opioid Stewardship
• Reducing Adverse Drug Events Related to Anticoagulant Use in Adults
• Healthcare Worker Implicit Bias Training and Education
• Deprescribing To Reduce Medication Harms in Older Adults
• Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events
• Failure To Rescue – Rapid Response Systems
• Prevention in Adults of Transmission of Infection With Multidrug-Resistant Organisms
• Patient Safety Practices Focused on Sepsis Prediction and Recognition
• Engaging Family Caregivers With Structured Communication for Safe Care Transitions
• Fatigue and Sleepiness of Clinicians Due to Hours of Service
• Active Surveillance Culturing of Clostridiodes difficile and Multidrug-Resistant Organisms: Methicillin-Resistant Staphylococcus aureus, Carbapenem-Resistant Enterobacterales, and Candida auris