Working Together to Tackle Our Most Pressing Safety Issues

I hope you’ve drawn encouragement and motivation from this week’s Patient Safety Awareness Week activities. Kudos to our colleagues at the Institute for Healthcare Improvement for raising awareness and moving the field to action.

This week provides an excellent occasion to examine the state of our field and AHRQ’s place within it. I am proud of the Agency’s contributions to the field and hope you’ve had the opportunity to reacquaint yourself with the breadth and depth of AHRQ’s patient safety resources. As the Nation’s lead agency dedicated to advancing patient safety research, AHRQ has supported the development of groundbreaking evidence about what works and tools that help providers implement those solutions.

AHRQ’s success is in part attributable to our ability to bring together clinicians, patients and families, researchers, health system leaders, and other interested parties to inform our work and ensure we have the greatest impact on patient and healthcare worker safety.

Late last year AHRQ hosted a pair of small, virtual meetings—a Patient Safety Roundtable and a Patient Safety Summit—to which we invited a representative group of stakeholders to focus on research priorities for the field of patient safety. They provided us with dozens of high-priority ideas. Reflecting on these meetings, I concluded that:   

1. The field still lacks a full account of patient safety harms across the entire continuum of care. This “unknown” limits our ability to keep patients safe. 
2. Patient safety measurement must evolve to more effectively support patient safety improvement.    
3. Multiple aspects of care in all healthcare settings are not “designed” with patient safety as a priority. 

Participants highlighted the need for additional research on how patient safety was addressed during the COVID-19 pandemic, with specific attention needed to ensure the safe use of telehealth. They also encouraged AHRQ to prioritize research on equity as a patient safety issue. This recommendation aligns with the work of the National Steering Committee for Patient Safety, which I co-chaired. Health equity is set forth as a core principle of patient safety in the National Action Plan to Advance Patient Safety. 

Participants agreed that a third specific research priority is diagnostic error. The quest to learn more about what contributes to diagnostic inaccuracies and delays has already been a focus area for AHRQ. We began investing in diagnostic safety and quality research in 2007 and have helped build interest around the topic. Diagnostic error harms too many and costs too much.  

When I think about options for tackling the issue of diagnostic safety, I’m reminded of the progress we’ve made with our successful Healthcare-Associated Infections (HAI) Program. AHRQ’s HAI Program is dedicated to understanding the problems that can harm patients, identifying what works to prevent infections, and then developing, testing, and refining tools to put that knowledge into practice on the front lines of care. AHRQ has achieved a great deal working alongside clinicians, patients, and other stakeholders focused on HAI prevention throughout government and the private sector.

I believe the Nation can expect reductions in diagnostic errors that match the progress we’ve achieved in the HAI Program if we get to work now. As with HAI prevention, improving diagnosis on the scale that’s needed will require dedicated effort and investments in order to prevent the substantial harm we know diagnostic error causes. 

Experience teaches us that patient safety improvement is most successful when an expansive, inclusive mix of stakeholders is involved. That’s why our standard approach is to engage a broad spectrum of stakeholders in our work. We have seen how contributions from diverse perspectives strengthen the solutions we create with our partners when we work together. 

Dr. Brady is Director of AHRQ’s Center for Quality Improvement and Patient Safety.

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