As of October 2004, it had been three years since the U.S. Congress funded the Agency for Healthcare Research and Quality (AHRQ) to establish the national patient safety research and implementation initiative. With these funds, AHRQ has committed to improving patient safety in the U.S. health care system by developing a comprehensive strategy for supporting expansion of knowledge about patient safety epidemiology and effective practices and by identifying and disseminating the most effective practices.

AHRQ contracted with RAND in September 2002 to serve as the evaluation center for its patient safety initiative. The evaluation center is responsible for performing a...

This chapter updates the information presented inEvaluation Report Iregarding the policy context that frames the AHRQ patient safety initiative (context evaluation), as well as the priorities and activities being pursued by AHRQ as it implements the initiative (input evaluation).

The events that led to formation and funding of the national patient safety initiative may be summarized as follows:

The science of patient safety was relatively immature as this initiative began in 2000. Knowledge of the epidemiology of safety in health care was limited, the body of published research was inadequate for establishing evidence regarding the effectiveness of practices...

This chapter focuses on the first of five system components of an effective patient safety system, as depicted in Figure 1.1 of this report. This component is monitoring progress and maintaining vigilance, as defined in the box above.

The ability to assess performance on established patient safety measures is essential for any system to be effective in minimizing risk of harm to patients. Therefore, it is vital for the health care community to have performance information that can be used to set priorities for reducing patient risk and consequences, and to monitor the community’s progress in achieving planned practice improvements....

This chapter focuses on the second and third of the five system components of an effective patient safety system, as depicted in Figure 1.1. These two components contribute to development of knowledge regarding patient safety epidemiology and effective practices and tools, as defined in the box above.

This chapter combines two components of the evaluation framework: establishing knowledge of epidemiology of patient safety risks and hazards; and developing effective patient safety practices and tools. In the epidemiology chapter ofEvaluation Report I, we examined what was known at that time about the epidemiology of patient safety risks and hazards, and...

This chapter focuses on the fourth of five system components of an effective patient safety system, as depicted in Figure 1.1. This component is building infrastructure for effective practices, as defined in the box above.

InEvaluation Report I, we delineated a number of infrastructure elements that are critical for the successful adoption of improved patient safety practices throughout the United States, including patient safety culture, information systems, adverse-event-reporting systems, interdisciplinary teams, multi-institutional collaborations, and quality-improvement systems and measures. We also highlighted how the FY 2000–FY 2001 patient safety projects are addressing infrastructure issues, and we explored the contributions...

This chapter focuses on the last of five system components of an effective patient safety system, as depicted in Figure 1.1. This component is achieving broader adoption of effective practices, as defined in the box above.

The large number of products and significant knowledge generated by the FY 2000–FY 2001 AHRQ patient safety projects provide content for implementation activities to support broader adoption of effective new practices. The challenge is to ensure that the results get into the hands of end users and that the tools and assistance are useful for facilitating integration of the new findings into practice...

The selection and tracking of patient-safety outcome measures is a key component of this evaluation. It is still too early in the initiative to be able to detect many changes in patient outcomes because the patient safety implementation activities are just beginning to build momentum. Growth in these activities should be observable, however, and should ultimately yield measurable improvements in patient outcomes.

Efforts to document improvements in national patient safety performance will depend on having standardized patient safety measures that can be tracked over time on a regional or national basis. Such measures are currently at an early stage of...

The 2003–2004 evaluation has focused on updating information related to the activities of the patient safety initiative and preparing to perform the product evaluation that will assess the effects of the initiative (i.e., the fourth component of the CIPP evaluation model). We have made extensive use of written materials, information on Web sites, and interviews with individuals involved in various aspects of patient safety work to gather information and assess progress and issues.

In 2004, nearly five years since the publication of the IOM reportTo Err Is Human, the national patient safety initiative is in full swing, and...