Health care providers should consider putting into practice 22 patient safety practices (PSPs) identified by the Agency for Healthcare Research and Quality (AHRQ). Implementing 10 of those PSPs is strongly encouraged by the AHRQ. The AHRQ examined 41 PSPs for their effectiveness and ease of implementation when coming to this recommendation. The AHRQ conducted this report to determine how effective PSP were in the actual hospital setting.
The 10 PSPs strongly encouraged by the AHRQ for implementation by health care providers include: (1) preoperative and anesthesia checklists to prevent operative and post-operative events; (2) 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) head-to-bed evaluations, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia; (5) hand hygiene; (6) a “Do Not Use” list for hazardous abbreviations; (7) multicomponent interventions to reduce pressure sores; (8) barrier precautions to prevent healthcare-associated infections; (9) the use of real-time ultrasound for central line placement; and (10) interventions to improve prophylaxis for venous thromboembolisms. Implementation of an additional 12 PSPs is also encouraged. The AHRQ determined that health care providers have sufficient knowledge to implement these 22 PSPs and that doing so would likely result in safer health care.
The AHRQ established PSPs one year after the issuance of the Institute of Medicine’s report, “To Err is Human: Building a Safer Health System.” That report detailed the types and frequency of errors that lead to adverse events. Following that report the AHRQ issued a report in 2001 entitled “Making Health Care Safer” in which PSP was defined as “a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures.”
Since that first report the ARHQ has noticed that some PSPs have resulted in unintended consequences, and others have shown to be highly context dependent, working effectively in research settings, but failing in broader implementation. It was these observations that caused the AHRQ to conduct a systemic literature review evaluating the evidence of a number of PSPs. The AHRQ noticed that some PSPs addressed frequently occurring problems like falls, venous, thromboembolism, potential adverse drug events and pressure sores which occur in approximately one out of every hundred hospitalizations. Some PSPs address serious but rare events like inpatient suicide, wrong-site surgery, and surgical items left inside a patient. In coming up with the 22 recommended PSP for implementation, the AHRQ was looking to identify the PSPs that are working, are implementable, and will result in a safer health care environment.