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  • Strategies to improve patient safety: Final report to congress required by the Patient Safety and Quality Improvement Act of 2005 (15 December 2021)


    Mark Hughes
    • USA
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Agency for Healthcare Research and Quality
    • 15/12/21
    • Everyone

    Summary

    This report was submitted to the United States Congress by the Department of Health and Human Services, in consultation with the Agency for Healthcare Research and Quality (AHRQ). It sets out effective strategies to improve patient safety and reduce medical error.

    Content

    The report suggests several measures which could accelerate progress in improving patient safety and encouraging the use of effective improvement strategies:

    • Patient safety research, measurement, and practice improvement should encompass analytical approaches that support learning from how and why things go right, and how to monitor risk without losing sight of the importance of addressing specific adverse events and harms.
    • There is a continuing need for more research to develop the patient safety evidence base, because safety is an important aspect of care for every patient in all healthcare disciplines, specialties, settings and modes of healthcare delivery. Expanding the use of research methods that explore and capture the complexity of patient safety problems and solutions will also advance the evidence base.
    • Translating evidence-based practices into real-world settings requires the development of clinically useful tools and infrastructure, and often foundational changes in organisational culture, leadership and patient engagement, teamwork, and communication. Implementation must be designed with, and from the perspectives of, the people who will be most affected and should extend across the wide range of stakeholders who intend to support patient safety.
    • Encouraging the development of learning health systems that integrate continuous learning and improvement in their day-to-day operations can speed the application of the most promising evidence to improve care. The concept of learning health systems can also facilitate the integration of patient safety practices with functions necessary to achieve other priorities, including the effectiveness, timeliness, efficiency, patient-centeredness and equity of healthcare.
    • The National Action Plan put forward by the National Steering Committee for Patient Safety has the potential to advance and align efforts to encourage the use of effective patient safety strategies. Many recommendations throughout the plan focus on ensuring that foundational factors are in place and sufficiently robust to enable the successful deployment and use of strategies and practices for reducing medical error and increasing patient safety.
    Strategies to improve patient safety: Final report to congress required by the Patient Safety and Quality Improvement Act of 2005 (15 December 2021) https://pso.ahrq.gov/sites/default/files/wysiwyg/strategies-improve-patient-safety-final.pdf
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