Making Healthcare Safer IV
A Continuous Updating of Patient Safety Harms and Practices
Making Healthcare Safer reports I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors. However, threats to patient safety are still emerging and evolving in a dynamic world.
Patient safety research is growing, spanning across more healthcare settings, and considers a wide array of contextual factors. The combination of emerging patient safety threats and the growing amount of published patient safety research, patient safety resources, and accrediting body standards makes it increasingly difficult to prioritize adoption and implementation of evidence-based practices. AHRQ’s fourth iteration of Making Healthcare Safer intends to address this issue by publishing evidence-based reviews of patient safety practices and topics as they are completed. This intentional release of updated reviews will aid healthcare organization leaders in prioritizing implementation of evidence-based practices in a timelier way. The report also will help researchers identify where more research is needed in a timelier way and assist policymakers in understanding which patient safety practices have the supporting evidence for promotion. Reviews will be posted below as they are completed.
Making Healthcare Safer IV was commissioned in 2022. To kick off the report, AHRQ explored the potential harms that may be associated with telehealth, which has grown exponentially during the wake of the COVID-19 pandemic to facilitate healthcare during a time when in-person clinical encounters between a patient and clinician was significantly reduced to help slow the spread of the virus. Because the benefits of telehealth became evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors, misdiagnosis, and privacy concerns are still being assessed. This review will serve as a baseline for the evidence of harms and patient safety practices to prevent or mitigate harms associated with the use of telehealth.
Making Healthcare Safer IV began with a horizon scan to identify emerging trends and needs in the patient safety field. A technical expert panel (TEP) was convened to prioritize which topics and patient safety practices, including updates to the ones covered in the previous Making Healthcare Safer reports, would be most beneficial to the field if addressed throughout the years of the fourth report. These discussions are summarized in the Prioritization Report.
AHRQ determined that the first rapid review would be on the potential harms that may be associated with telehealth, which has grown exponentially during the wake of the COVID-19 pandemic to facilitate healthcare during a time when in-person clinical encounters between a patient and clinician was significantly reduced to help slow the spread of the virus. Because the benefits of telehealth became evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors, misdiagnosis, and privacy concerns are still being assessed. This review will serve as a baseline for the evidence of harms and patient safety practices to prevent or mitigate harms associated with the use of telehealth. Since AHRQ asked for this topic to be explored first, it was not discussed during the TEP convening.
The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated source of information for healthcare providers, health system administrators, researchers, and government agencies. A set of tables compares the patient safety practices among the reports.
Chapters
Prioritization of Patient Safety Practices for Making Healthcare Safer IV
Potential Harms Resulting From Video-Based Telehealth
Patient and Family Engagement
Surgical Report Cards and Outcome Measurements
Opioid Stewardship
Reducing Adverse Events Related to Anticoagulants
Implicit Bias Training
Deprescribing
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events
Failure To Rescue—Rapid Response Systems
Prevention in Adults of Transmission of Infection With Multidrug-Resistant Organisms
Sepsis Prediction, Recognition, and Intervention
Engaging Family Caregivers
Fatigue and Sleepiness of Clinicians Due to Hours of Service
Infection Surveillance for Clostridiodes difficile, Methicillin-Resistant Staphylococcus aureus (MRSA), Carbapenem-Resistant Enterobacterales (CRE), and Candida auris
