Comparison Tables for Making Healthcare Safer Reports
The tables below compare three editions of the Agency for Healthcare Research and Quality’s Making Health Care Safer report.
The first edition, published in 2001, was developed following the 1999 publication of To Err is Human: Building a Safer Health System, the seminal National Academy of Medicine report that elevated awareness of longstanding risks and patient harms occurring in the U.S. healthcare system. The inaugural report consisted of 50 patient safety practices in eight categories encompassing commonly occurring care and disease specific adverse events and associated systemic and contextual factors.
In 2013, AHRQ published a second edition of Making Health Care Safer. That report added new evidence-based safety practices while updating some practices with new evidence, and contained a total of 41 patient safety practices.
AHRQ’s third and most recent Making Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm areas. It includes evidence for more specific harm areas than the preceding reports.
Taken together, the reports cover a wide range of patient safety practices. Methodologically, the practices (or PSPs) are similar but not identical. Following the first report, PSPs were included in subsequent reports if there was evidence for a new practice for improving patient safety or the topic was considered a pressing issue at the time of the report development. Subsequent reports also updated some PSPs of the previous report because there was new evidence available for the PSP or the topic was still considered a pressing issue for patient safety. Other PSPs were not updated because either there was no new evidence available or the topic was not considered a priority issue when the report was developed. For these reasons, a summary of evidence is not available for many PSPs. The cells indicating “(Not reviewed)” reflect that the topic was not reviewed and a summary of evidence is not available.
Although the methodology and context of collection of the patient safety practices of these three reports may vary, they serve as a consolidated source of evidence-based information for healthcare providers, health system administrators, researchers, and government agencies to use in patient safety improvement efforts.
Adverse Drug Events (ADEs): General Medication Topics
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Computer Adverse Drug Event Detection and Alerts |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Unit-Dose Drug Distribution Systems |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Automated Medication Dispensing Devices |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Computerized Physician Order Entry With Clinical Decision Support Systems |
Summary of Evidence |
Update |
(Not reviewed) |
The Clinical Pharmacist's Role in Preventing Adverse Drug Events |
Summary of Evidence |
Update |
(Not reviewed) |
Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants |
Summary of Evidence |
Update |
(Not reviewed) |
The Joint Commission’s “Do Not Use” List |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Medication Reconciliation Supported by Clinical Pharmacists |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
ADEs: Harms Due to Anticoagulants
ADEs: Harms Due to Diabetic Agents
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Standardized Insulin Protocols |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Teach-Back |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
ADEs: Reducing Adverse Drug Events in Older Adults
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Deprescribing |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Use of STOPP Criteria |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
ADEs: Harms Due to Opioids
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Opioid Stewardship |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Medication-Assisted Treatment |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
ADEs: Infusion Pumps/Medication Error
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Smart Pumps and Other Protocols for Infusion Pumps |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Structured Process Changes/Workflow Redesign |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Staff Education and Training |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Alarm Fatigue
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Safety Culture |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Alarm Risk Assessment |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Care Transitions
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Interventions To Improve Care Transitions at Hospital Discharge |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
BOOST: Better Outcomes for Older Adults Through Safe Transitions |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
CTI: Care Transition Intervention |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
TCM: Transitional Care Model |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Cross-Cutting: Teamwork Training
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Crew Resource Management and its Applications in Medicine |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Teamwork and Team Training |
(Not reviewed) |
Summary of Evidence |
Update |
Cross-Cutting: Health Information Technology
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Information Transfer |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Clinical Decision Support |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Cross-Cutting: Other Topics
Delirium
Diagnostic Error
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Patient Safety Practices Targeted at Diagnostic Errors |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Clinical Decision Support |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Performance Review and Feedback |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Result Notification Systems |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Staff Education and Training |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Failure To Rescue
General Clinical Topics
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Safety During Transport of Critically Ill Patients |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Nutritional Support |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Pneumococcal Vaccination Prior to Hospital Discharge |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Pain Management |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients |
Summary of Evidence |
Update |
(Not reviewed) |
Inpatient Intensive Glucose Control Strategies To Reduce Death and Infection |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Tubing Miscommunications |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Identifying Patients at Risk for Suicide |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Infection Control: Carbapenem-Resistant Enterobacteriaceae
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Transmission-Based Precautions: Contact Precautions, Patient Isolation, Dedicated Staff |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Infection Control: Central Line-Associated Bloodstream Infections
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Prevention of Central Line-Associated Bloodstream Infections |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Interventions To Allow the Reuse of Single-Use Devices |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Infection Control: Clostridioides difficile Infection
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance - Clostridium Difficile and Vancomycin-resistant Enterococcus |
Summary of Evidence
(Also listed in Vancomycin-resistant Enterococcus under Miscellaneous section) |
(Not reviewed) |
(Not reviewed) |
Antimicrobial Stewardship |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Testing |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Surveillance |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Hand Hygiene |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Environmental Cleaning & Decontamination |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Multicomponent Prevention Interventions |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Infection Control: Infections Due to Other Multidrug-Resistant Organisms
Infection Control: Miscellaneous Topics
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance - Clostridium Difficile and Vancomycin-Resistant Enterococcus |
Summary of Evidence
(Also listed in Clostridium Difficile) |
(Not reviewed) |
(Not reviewed) |
Prevention of Ventilator-Associated Pneumonia |
Summary of Evidence |
Update |
(Not reviewed) |
Practices To Improve Handwashing Compliance |
Summary of Evidence |
Update |
Refer to CDI and MDROs chapters |
Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections |
Summary of Evidence |
Update |
Refer to MDROs (PDF, 2.7 MB) and CRE chapters |
Infection Control: Urinary Tract Infection
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Prevention of Nosocomial Urinary Tract Infections |
Summary of Evidence |
Update |
(Not reviewed) |
Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections |
Summary of Evidence |
Update |
(Not reviewed) |
Patient and Family Engagement
Patient Identification Errors in the Operating Room
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Prevention of Misidentifications |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Operating Room/Surgery-Specific Practices |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Radiological
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Interventions To Prevent Contrast-Induced Acute Kidney Injury |
Summary of Evidence |
Update
(all patients) |
(Not reviewed) |
Preventing Patient Death or Serious Injury Associated With Radiation Exposure From Fluoroscopy and Computed Tomography |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Safety Practices for Hospitalized or Institutionalized Elders
Sepsis Recognition
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Screening Tools and Algorithms |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Patient Monitoring Systems |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |
Surgery, Anesthesia, and Perioperative Medicine
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Localizing Care to High-Volume Centers |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Learning Curves for New Procedures - the Case of Laparoscopic Cholecystectomy |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Prevention of Surgical Site Infections |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Ultrasound Guidance of Central Vein Catheterization |
Summary of Evidence |
Update |
(Not reviewed) |
Prevention of Surgical Items Being Left Inside Patient |
Summary of Evidence |
Update |
(Not reviewed) |
Pre-Anesthesia Checklists To Improve Patient Safety |
Summary of Evidence |
Update |
(Not reviewed) |
The Impact of Intraoperative Monitoring on Patient Safety |
Summary of Evidence |
(Not reviewed) |
(Not reviewed) |
Beta-blockers and Reduction of Perioperative Cardiac Events |
Summary of Evidence |
Update |
(Not reviewed) |
Use of Report Cards and Outcome Measurements To Improve Safety of Surgical Care: American College of Surgeons National Surgical Quality Improvement Program |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Operating Room Integration and Display Systems |
(Not reviewed) |
Summary of Evidence |
(Not reviewed) |
Venous Thromboembolism
Patient Safety Practices |
MHS I (2001) |
MHS II (2013) |
MHS III (2020) |
Prevention of Venous Thromboembolism |
Summary of Evidence |
Update |
(Not reviewed) |
Post-Surgical Prophylaxis Using Aspirin |
(Not reviewed) |
(Not reviewed) |
Summary of Evidence |