Assessment of the National Patient Safety Initiative

Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report I

Donna O. Farley
Sally C. Morton
Cheryl L. Damberg
Allen Fremont
Sandra H. Berry
Michael D. Greenberg
Melony Sorbero
Stephanie S. Teleki
Karen Ricci
Nancy Pollock
Copyright Date: 2005
Published by: RAND Corporation
Pages: 112
https://www.jstor.org/stable/10.7249/tr203ahrq
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  • Book Info
    Assessment of the National Patient Safety Initiative
    Book Description:

    In September 2002, RAND contracted with the U.S. Agency for Healthcare Research and Quality to serve as the evaluation center for its national patient safety initiative. This report assesses the context and goals that were the foundation for the initiative, documents the baseline status of the activities being undertaken, and identifies priorities the researchers believe will have the strongest positive impact on the future of AHRQ's patient safety initiative.

    eISBN: 978-0-8330-5997-0
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. PREFACE
    (pp. iii-iv)
  3. Table of Contents
    (pp. v-vi)
  4. TABLE OF FIGURES
    (pp. vii-viii)
  5. TABLE OF TABLES
    (pp. ix-x)
  6. EXECUTIVE SUMMARY
    (pp. xi-xx)
  7. ACRONYMS
    (pp. xxi-xxii)
  8. ACKNOWLEDGEMENTS
    (pp. xiii-xiv)
  9. CHAPTER 1. INTRODUCTION
    (pp. 1-8)

    Congress has placed a high priority on making a safer U.S. health care system. It has given a mandate to the Agency for Healthcare Research and Quality (AHRQ), an agency within the Department of Health and Human Services (DHHS), to establish a patient safety research and development initiative. This mandate holds AHRQ accountable for helping health care providers reduce medical errors and improve patient safety. AHRQ, in turn, is committed to improving patient safety in the U.S. health care system by ensuring that the extensive work supported by AHRQ and other organizations (1) addresses the many aspects of achieving safe...

  10. CHAPTER 2. CONTEXT EVALUATION
    (pp. 9-14)

    This chapter provides an overview of the historical context and sequence of events that led to and framed the formation of the AHRQ patient safety initiative. Table 2.1 presents a timeline of these events, with additional detail provided in the chapter narrative. These events continue to influence the strategy and activities of AHRQ and other federal agencies as they fulfill their roles to help improve patient safety practices. Our understanding of the history has been informed by factual information in documents and web sites and by information and viewpoints shared by the stakeholders we interviewed. We conclude with a brief...

  11. CHAPTER 3. INPUT EVALUATION
    (pp. 15-22)

    This chapter examines AHRQ’s overall strategy and goals, structure, and approaches with respect to its patient safety activities and assesses the existing strategy against the alternatives. This aspect of our evaluation has been informed by factual information in documents and web sites, and by information and viewpoints shared by the stakeholders we interviewed. In this review, we describe the patient safety activities and how they fit into the broader AHRQ organization, the processes involved in starting up the initiative, and related budgets. The effects of the policy and environmental context on AHRQ activities, as discussed in the previous chapter, are...

  12. CHAPTER 4. PROCESS EVALUATION: MONITORING PROGRESS AND MAINTAINING VIGILANCE
    (pp. 23-32)

    For any system to be effective in minimizing risk of harm to patients receiving health care services, it must have the capability to measure and monitor performance on patient safety measures. A well-designed and well-executed monitoring system provides data that can be used for problem identification and assessment as well as for tracking progress in improving patient safety practices.

    In this chapter, we review the status of patient safety measures and data as of September 2003, which provides a baseline for tracking future development and monitoring efforts through our process evaluation. We also review the status of patient safety monitoring...

  13. CHAPTER 5. PROCESS EVALUATION: KNOWLEDGE OF EPIDEMIOLOGY OF PATIENT SAFETY RISKS
    (pp. 33-40)

    The overall goals for patient safety epidemiology are to develop the capability to examine levels and variation in incidence rates of errors and adverse events across settings, institutions, regions, and populations, and to track changes in rates over time. Two factors are essential for understanding the epidemiology of patient safety. These are (1) a common understanding of issues that fall under the umbrella of medical errors and patient safety; and (2) scientifically sound methods to measure errors and their causes. Currently, neither of these conditions exists, but progress is being made on both fronts.

    This chapter examines what is currently...

  14. CHAPTER 6. PROCESS EVALUATION: ESTABLISHING EFFECTIVE PATIENT SAFETY PRACTICES
    (pp. 41-50)

    The development of scientific evidence for patient safety practices has involved two methodological challenges. The first is that the “landscape” of practices that might reduce error rates and patient harm is not clearly bounded. The second is that, for many of these interventions, it is not possible to evaluate performance using traditional scientific methods (e.g., randomized clinical trials), which makes it difficult to establish evidence for their effectiveness.

    This chapter describes the state of knowledge regarding which practices have been documented to be effective in reducing medical errors and preventing adverse events in our health care system and, specifically, how...

  15. CHAPTER 7. PROCESS EVALUATION: BUILDING INFRASTRUCTURE FOR EFFECTIVE PRACTICES
    (pp. 51-62)

    Patient safety infrastructure is a broad concept that includes capabilities at both the national level (e.g., research capacity to generate new knowledge on effective practices, a national reporting and monitoring system) and within local health care delivery organizations (e.g., information systems, a patient safety–oriented culture). Another part of infrastructure, which we refer to as the "macro-environment," encompasses external regulatory and market forces that influence patient safety activities. The existence of a basic infrastructure is essential for efforts to improve patient safety.

    During the first two years of the patient safety program, AHRQ has focused resources on supporting projects that...

  16. CHAPTER 8. PROCESS EVALUATION: ACHIEVING BROADER ADOPTION OF EFFECTIVE PRACTICES
    (pp. 63-72)

    Although it is too early in the evaluation process to determine whether and to what extent the safety practices emerging from the AHRQ-funded work are being adopted, it is an optimal time to consider the capabilities that will be needed for broad and successful adoption of effective patient safety practices. We focus on issues regarding the facilitation of information exchange, the transfer of knowledge and practices to the broader health care community, and the dissemination of products from the patient safety portfolio of projects.

    The following key questions are assessed here and will be tracked over the four-year evaluation:

    To...

  17. CHAPTER 9. CONCLUSION
    (pp. 73-76)

    In this first evaluation cycle, we have observed, documented, and assessed the start-up and initial operations through September 2003 of the AHRQ patient safety initiative, learning from participants and other stakeholders about the activities and interactions involved in the process. These individuals also have shared with us their concerns and ideas for future work.

    In general, both external leaders and the AHRQ staff believe the agency has done an impressive job in starting the patient safety initiative and has taken a productive approach for spending the patient safety funding on research to generate new knowledge. The patient safety initiative serves...

  18. APPENDIX A. ORGANIZATIONS AND PROJECT GROUPS INVOLVED IN THE PATIENT SAFETY INITIATIVE
    (pp. 77-80)
  19. APPENDIX B. PATIENT SAFETY PROJECTS WITH POTENTIAL TO GENERATE PATIENT SAFETY EPIDEMIOLOGY INFORMATION
    (pp. 81-82)
  20. APPENDIX C. ANALYSIS OF AHRQ PATIENT SAFETY PROJECTS IN THE CONTEXT OF THE EVIDENCE REPORT AND NQF SAFE PRACTICES
    (pp. 83-84)
  21. REFERENCES
    (pp. 85-88)