07:11am Friday 23 August 2019

New Patient Safety Strategies Outlined in Report Based on Decade of Research

Robert Wachter, MD

Robert Wachter, MD

The report, “Making Health Care Safer II,” was issued by principal investigators Robert M. Wachter, MD, associate chair of the UCSF Department of Medicine and chief of UCSF Division of Hospital Medicine; Paul Shekelle of RAND Corporation, a nonprofit institution that helps improve policy and decision making through research and analysis; and Peter Pronovost, MD, of Johns Hopkins University.

UCSF faculty helped lead the team that produced the landmark 2001 evidence report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices” – the first attempt to apply evidence to the field of patient safety, Wachter noted. That 2001 report was immediately preceded by two major Institute of Medicine reports, “To Err is Human: Building a Safer Health System” and “Crossing the Quality Chasm,” which together galvanized the modern patient safety and quality improvement movements in the United States.

The new report, Wachter said, “illustrates that we have made substantial progress in certain areas, such as preventing falls, central line infections and surgical complications, and that we have a far better understanding of the role of context and implementation. But it also demonstrates that we still have a long way to go before we can declare victory in the battle to keep patients safe.”

UCSF faculty also contributed research papers to the update, which shows that significant progress has been made in patient safety research, now making it possible to know what strategies work, and to provide clinicians and hospitals with a sound basis for integrating proven strategies into their day-to-day delivery of patient care.

The 10 strategies, if widely implemented, have the potential to vastly improve patient safety and save lives in U.S. health care institutions, the report says, by helping prevent harmful events such as medication errors, bedsores and health care-associated infections.

Ten of the 41 strategies were published as papers in a special supplement to Annals of Internal Medicine.

The entire report, including evidence reviews for all 41 patient safety strategies, can be found on the AHRQ website.

10 Strongly Recommended Patient Safety Strategies in AHRQ Report:

  1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events
  2. Bundles that include checklists to prevent central line–associated bloodstream infections
  3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
  4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia
  5. Hand hygiene
  6. The do-not-use list for hazardous abbreviations
  7. Multicomponent interventions to reduce pressure ulcers
  8. Barrier precautions to prevent health care–associated infections
  9. Use of real-time ultrasonography for central line placement
  10. Interventions to improve prophylaxis for venous thromboembolisms


Wachter’s Interview with KQED:

Checklists and More: Systems Matter in Aviation, Can Save Lives in Health Care, Too

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