Accelerating Progress in Patient Safety

Last March, during national Patient Safety Awareness Week (PSAW) 2020, the World Health Organization declared COVID-19 to be a pandemic. As we commemorate PSAW 2021—an annual event organized by our partners at the Institute for Healthcare Improvement—we celebrate the healthcare professionals who worked tirelessly this year to ensure the safety of patients.

The protocols and practices developed over the past two decades by the patient safety field helped delivery systems adapt and innovate to address the pandemic. Without their efforts, the national outcomes of COVID-19 would have been much worse. AHRQ salutes the courage, dedication, collaboration, and resourcefulness of America's patient safety researchers, coaches, and implementers.

Twenty years ago, in the Crossing the Quality Chasm report, the Institute of Medicine (now the National Academy of Medicine) put forth an aspirational vision of a 21st-century healthcare system that included a call for making patient safety a "system priority." This past year has shown us how far we were from achieving this vision in 2020.

The challenges created by the pandemic, however, also led to unprecedented innovation in how healthcare is delivered in the United States. As we transition from pandemic response into pandemic recovery, we will be able to learn from this experience and make the vision a reality if we are thoughtful and deliberate.

At AHRQ, we are using PSAW 2021 as an opportunity to rededicate ourselves to our mission of helping build a 21st-century healthcare system that delivers high-quality, safe, equitable, high-value care.

We already have a blueprint for building safety into the system. Before and during the pandemic, leaders from 27 organizations came together to form the National Steering Committee for Patient Safety, co-chaired by AHRQ. The committee included representation from healthcare systems, patients and care partners, professional societies, safety and quality organizations, regulatory and accrediting bodies, and Federal agencies.

We worked together to produce Safer Together: A National Action Plan to Advance Patient Safety. The plan offers 17 recommendations organized around the four foundational and interdependent areas of safety culture and leadership, patient and family engagement, workforce safety, and the learning health system. The recommendations are declarations of core values that safety-focused organizations should strive to support—such as sharing information widely for learning and promoting a culture of trust and respect. The plan is accompanied by a Self-Assessment Tool and an Implementation Resource Guide. With these, all healthcare organizations can follow an actionable path to strengthen their foundation for patient safety.

AHRQ also has produced a compendium of evidence-based practices to help health systems and professionals make the safe thing to do the easy thing to do. While system redesign requires significant effort, improving safety is possible today. Making Healthcare Safer III is a comprehensive toolkit for making care safer. Its reviews of 47 patient safety practices address improvement across a range of settings and topics that include clinical decision support, rapid response teams, and antimicrobial stewardship.

Over the past year, AHRQ has produced new patient safety tools and resources tailored to the pandemic, including guides to assist dental care during COVID-19 and a patient-experience of care survey for use after telehealth visits.

We recognize, however, the enormous need for new patient safety evidence. We must evaluate how safety was ensured during the pandemic, build an evidence base for the safe use of telehealth, and address needs identified in the National Action Plan.

AHRQ continues to support and shape the patient safety research agenda in response to the most important questions that patients, clinicians, and others have about how to prevent healthcare harm. When we combine research that demonstrates how to keep patients safe with healthcare professionals who are ready to apply this knowledge, we accelerate improvement in patient safety.

Dr. Brady is Director of AHRQ's Center for Quality Improvement and Patient Safety. Dr. Meyers is AHRQ's Acting Director.

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