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New Patient Safety Strategies Outlined in Report

March 06, 2013
News Office: Karin Rush-Monroe (415) 502-6397

The Agency for Healthcare Research and Quality (AHRQ) has released a new report that identifies the top 10, evidence-based patient safety strategies available to clinicians.

Dr. Robert Wachter

Robert Wachter, MD

The report, "Making Health Care Safer II," was issued by principal investigators Dr. Robert M. Wachter, associate chair of the UCSF Department of Medicine and chief of UCSF Division of Hospital Medicine; Paul Shekelle of RAND Corporation, a nonprofit institution that helps improve policy and decision making through research and analysis; and Dr. Peter Pronovost of Johns Hopkins University.

UCSF faculty helped lead the team that produced the landmark 2001 evidence report, "Making Health Care Safer: A Critical Analysis of Patient Safety Practices" — the first attempt to apply evidence to the field of patient safety, Wachter noted. That 2001 report was immediately preceded by two major Institute of Medicine reports, "To Err is Human: Building a Safer Health System" and "Crossing the Quality Chasm," which together galvanized the modern patient safety and quality improvement movements in the United States.

The new report, Wachter said, "illustrates that we have made substantial progress in certain areas, such as preventing falls, central line infections and surgical complications, and that we have a far better understanding of the role of context and implementation. But it also demonstrates that we still have a long way to go before we can declare victory in the battle to keep patients safe."

10 Strongly Recommended Patient Safety Strategies in AHRQ Report


1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events

2. Bundles that include checklists to prevent central line–associated bloodstream infections

3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols

4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia

5. Hand hygiene

6. The do-not-use list for hazardous abbreviations

7. Multicomponent interventions to reduce pressure ulcers

8. Barrier precautions to prevent health care–associated infections

9. Use of real-time ultrasonography for central line placement

10. Interventions to improve prophylaxis for venous thromboembolisms

UCSF faculty also contributed research papers to the update, which shows that significant progress has been made in patient safety research, now making it possible to know what strategies work, and to provide clinicians and hospitals with a sound basis for integrating proven strategies into their day-to-day delivery of patient care.

The 10 strategies, if widely implemented, have the potential to vastly improve patient safety and save lives in U.S. health care institutions, the report says, by helping prevent harmful events such as medication errors, bedsores and health care-associated infections.

Ten of the 41 strategies were published as papers in a special supplement to Annals of Internal Medicine.

The entire report, including evidence reviews for all 41 patient safety strategies, can be found on the AHRQ website.

More on Patient Safety

UCSF Medical Center has tips to ensure patient safety as well as a hotline for people to report concerns. Click here for more information.

For fact sheets and research from the independent, not-for-profit National Patient Safety Foundation, visit the foundation's website.

About UCSF Medical Center
UCSF Medical Center consistently ranks as one of the top 10 hospitals in the United States. Recognized for innovative treatments, advanced technology, collaboration among health care professionals and scientists, and a highly compassionate patient care team, UCSF Medical Center serves as the academic medical center of the University of California, San Francisco. The medical center's nationally preeminent programs include children's health, the brain and nervous system, organ transplantation, women's health and cancer. It operates as a self-supporting enterprise within UCSF and generates its own revenues to cover the operating costs of providing patient care.

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