In early 2000, the Institute of Medicine (IOM) published the report entitled To Err is Human: Building a Safer Health System, calling for leadership from the U.S. Department of Health and Human Services (DHHS) in reducing medical errors, and recommending the Agency for Healthcare Research and Quality (AHRQ) as the lead agency for patient safety research and practice improvement (IOM, 2000). In response to the IOM report, the Quality Interagency Coordination Task Force (QuIC) identified more than 100 actions designed to create a national focus on reducing errors, strengthen the patient safety knowledge base, ensure accountability for safe health care...

This chapter updates the information presented in Evaluation Reports I through III regarding 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 continues to carry out the initiative (input evaluation).

The historical context that led to formation and funding of the AHRQ patient safety initiative may be summarized as follows:

The science of patient safety was relatively immature as this initiative began, including limited knowledge of the epidemiology of safety in health care, an inadequate body of published research to establish evidence regarding the...

The ability to assess performance on established patient safety measures is vital to the health care community for reducing the risk of harm to patients and the consequences of such harm. This information will also enable AHRQ to report to Congress on the results of its investments in patient safety research and dissemination so that appropriate adjustments can be made to the patient safety project investments.

A major goal of the AHRQ patient safety initiative is to establish a national data capability that would enable aggregation of patient safety data from local, regional, and state levels, and allow for tracking...

This chapter addresses two topics: the epidemiology of patient safety risks and hazards and the establishment of effective patient safety practices and tools. These system components are examined through our ongoing review of AHRQ’s complete set of patient safety projects as well as the new patient safety–related grants funded in FY 2006.

The primary approach of this evaluation has been to focus on the scope of work and contributions of the projects funded by AHRQ in these areas, and to develop information on where new knowledge might be expected to emerge for ultimate use by health care providers and...

Building a supportive infrastructure is critical for successful adoption of improved patient safety practices throughout the United States. Infrastructure refers not only to training individuals to have the capacity to act but also to building mechanisms for dissemination of information and products so that new findings and tools can be applied in real world settings. Our overall evaluation approach has been to identify several key infrastructure elements for achieving readiness for adoption of effective safety practices by health care providers, and to assess developments for each of these elements and AHRQ’s contributions to them over time. Table 5.1 presents the...

Five years into its patient safety initiative, AHRQ has been turning its attention to actions that support broader adoption of effective patient safety practices. A wealth of information is emerging from the AHRQ-funded patient safety projects that needs to be synthesized and packaged into products that health care providers can use to facilitate their safety improvement efforts. With diffusion of use of these practices across the health care system, effects should be seen in trends for outcome measures, as safety improvements increasingly prevent occurrence of adverse events. Table 6.1 presents the evaluation questions regarding the adoption of effective practices by...

A key component of this evaluation is the identification and tracking of measures in preparation for assessing the effects of the AHRQ patient safety initiative, while simultaneously informing the development and refinement of new measures and related data capabilities. Our overall approach has been to characterize baseline trends in selected patient safety outcomes for use in assessing improvements of those outcomes as subsequent data become available.

\Although AHRQ first funded patient safety projects in FY 2000 and FY 2001, we did not expect the results of these projects, and of other related activity by AHRQ and its collaborators, to have...

Over the course of this initiative, the patient safety evaluation center has examined actions undertaken by AHRQ to improve patient safety as well as related developments nationwide. In the process evaluation, we have documented the potential contributions of the groups of AHRQ-funded patient safety projects to expansion of knowledge for patient safety epidemiology and practices. We also have tracked activities undertaken directly by AHRQ for development of a national patient safety data network, building infrastructure to support adoption of newly proven practices, and dissemination of the knowledge and products from all this work to the end users—health care providers...