The fourth installment of the Making Healthcare Safer (MHS) series of reviews will mark close to a quarter century’s progress in efforts to meet the challenge of reducing and ultimately eliminating preventable patient harm. Throughout this patient safety journey, the MHS series has synthesized and disseminated evidence on the effectiveness of patient safety practices (PSPs).
For this project, we define PSPs as interventions, strategies, or approaches intended to prevent or mitigate unintended consequences of the delivery of healthcare and to improve the safety of healthcare for patients.1 The MHS series has guided the field about what works, and where more research and rigorous evaluation is needed.1 The science and practice of patient safety improvement has evolved in the last 20 years, and while certain areas2-6 have realized improvements, healthcare continues to struggle with improvement rates much lower than desired. A recent report from the National Academies of Sciences, Engineering, and Medicine goes as far to claim that “the country is at a relative standstill in patient safety progress,”7 a claim supported by a recent meta-analysis indicating that as many as 1 in 20 patients continue to experience preventable harm.8 A recent report from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) revealed that 25 percent of Medicare patients experience harm, with 43 percent of those harm events judged to be preventable.9 The leading types of harm found in the OIG report (i.e., medication errors, pressure ulcers, surgical procedural errors, and infections) align with the topics in the initial MHS report issued over 20 years ago. Additionally, the coronavirus disease 2019 (COVID-19) pandemic has eroded some of the hard-won gains in reducing preventable harm such as central line-associated blood stream infections (CLABSIs).10 The current state of the patient safety movement heightens the importance of this fourth installment of MHS as an opportunity to renew focus on foundational elements of safe patient care and move the field forward.
The purpose of this report is to identify the PSPs that merit highest priority for inclusion in the MHS IV series of reviews. An overview of the MHS IV project is provided in Figure 1. Our analytic framework for this project (Table 1) builds on frameworks from past MHS reports as well as the broader literature on classifying and analyzing PSPs.11 We have made efforts to align with terminology from the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Net (PSNet) to promote consistency across AHRQ activities. The purpose of this framework is to organize the overall scope of the effort and guide organization of the final report.
Figure 1. Overview of the Making Healthcare Safer IV Project
EPC = Evidence-based Practice Center; PSP = patient safety practice; TEP = technical expert panel
Table 1. Framework for organizing patient safety practices
| Domain | Description | Attributes To Consider |
|---|---|---|
| Safety Target | The safety targets include specific preventable harms (e.g., hospital-acquired infections), care delivery processes (e.g., medication management), and performance shaping factors (e.g., fatigue, device design). |
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| Setting of Care/ Clinical Area | The setting of care and clinical area may include the focus of care delivery, the physical setting, transitions between settings, and the technological mediation of care. |
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| PSP Attributes | Attributes of the PSP include its approach to improving safety and related factors that impact its implementation and effectiveness. |
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| Contextual Factors | Contextual factors include a broad range of internal (to the organization) and external concepts that may impact the PSP’s implementation or effectiveness. |
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Preliminary Prioritization of Patient Safety Practices (PSPs)
Appropriateness and Regrouping
From the horizon scan and previous Making Healthcare Safer (MHS) reports, we identified a total of 136 PSPs that could be reviewed. The MHS I–III reports together included 108 PSPs in 27 categories (see Appendix C). The horizon scan yielded 26 PSPs that are modifications of prior PSPs or not included in prior reports (see Appendix A). We excluded 16 items that did not meet the appropriateness criterion for being a specific PSP (as listed in Table 3). We excluded 41 PSPs that were merged into one of the other PSPs in our revised framework for classifying the PSPs (as listed in Table 4).
Table 3. List of items that did not meet appropriateness criterion for being a specific PSP
| Category (listed in proposal) | Item | Reason Not Considered a PSP |
|---|---|---|
| Adverse Drug Events: General Medication Topics | The Joint Commission’s “Do Not Use” List | This is a list, with no clear intervention |
| Alarm Fatigue | Alarm Risk Assessment | This is a “problem-finding” process with no clear intervention |
| Cross-Cutting: Other Topics | Monitoring, Auditing, and Feedback | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention |
| Diabetes and Hyperglycemia Management | Inpatient Intensive Glucose Control Strategies To Reduce Death and Infection | The recommendation from MHS II was to stop this PSP (strong evidence of harm; moderate to high evidence it does not help) |
| Teach-Back | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention | |
| Education and Training | Staff Education and Training (Simulation) | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention |
| General Clinical Topics | Nutritional Support | Practice is now standard of care |
| Infection Control: Miscellaneous Topics | Pneumococcal Vaccination Prior to Hospital Discharge | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention |
| Patient and Family Engagement | Obtaining Informed Consent From Patients | Practice was assessed to currently be viewed as standard of care or quality improvement rather than a safety intervention |
| Safety Practices for Hospitalized or Institutionalized Elders | Geriatric Evaluation and Management Units for Hospitalized Patients | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention |
| Multidisciplinary Geriatric Consultation Services | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention | |
| Surgery, Anesthesia, and Perioperative Medicine | Learning Curves for New Procedures – the Case of Laparoscopic Cholecystectomy | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention |
| Localizing Care to High-Volume Centers | Practice was assessed to currently be viewed as quality improvement rather than a safety intervention | |
| Operating Room Integration and Display Systems | Practice was assessed to currently be viewed as standard of care or quality improvement rather than a safety intervention | |
| The Impact of Intraoperative Monitoring on Patient Safety | Practice was assessed to currently be viewed as standard of care or quality improvement rather than a safety intervention | |
| Beta-Blockers and Reduction of Perioperative Cardiac Events | PSP was assessed to no longer be supported by evidence (harms exceed benefits, no longer recommended) |
MHS = Making Healthcare Safer; PSP = patient safety practice
Table 4. List of PSPs that were merged into one of the PSPs in our revised framework
| Category | Item |
|---|---|
| Adverse Drug events: General Medication Topics | Computer Adverse Drug Event Detection and Alerts |
| Medication Reconciliation Supported by Clinical Pharmacists | |
| The Clinical Pharmacist's Role in Preventing Adverse Drug Events | |
| Adverse Drug Events: Harms due to Anticoagulants | Single Provider |
| Adverse Drug Events: Infusion Pumps/Medication Error | Staff Education and Training |
| Structured Process Changes/Workflow Redesign | |
| Adverse Drug Events: Reducing Adverse Drug Events in Older Adults | Use of Screening Tool of Older People's Prescriptions (STOPP) Criteria |
| Alarm Fatigue | Safety Culture |
| Care Transitions | Better Outcomes for Older Adults Through Safe Transitions |
| Care Transition Intervention | |
| Interventions To Improve Care Transitions at Hospital Discharge | |
| Transitional Care Model | |
| Cross-Cutting: Health Information Technology | Computerized Physician Order Entry With Clinical Decision Support Systems |
| Information Transfer | |
| Delirium | Staff Education and Training |
| Diagnostic Error | Patient Safety Practices Targeted at Diagnostic Errors |
| Staff Education and Training | |
| Education and Training | Crew Resource Management and its Applications in Medicine |
| Failure To Rescue | Sepsis Recognition – Patient Monitoring Systems |
| Sepsis Recognition – Screening Tools and Algorithms | |
| Multicomponent Sepsis Interventions | |
| General Clinical Topics | Tubing Miscommunications |
| Infection Control: Clostridioides difficile Infection | Environmental Cleaning & Decontamination |
| Hand Hygiene | |
| Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance - Clostridioides difficile and Vancomycin-Resistant Enterococcus | |
| Surveillance | |
| Testing | |
| Infection Control: Infections due to Other Multidrug-Resistant Organisms | Environmental Cleaning & Disinfection |
| Hand Hygiene | |
| Surveillance | |
| Transmission-Based Precautions: Contact Precautions, Patient Isolation, Dedicated Staff | |
| Infection Control: Miscellaneous Topics | Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections |
| Practices To Improve Handwashing Compliance | |
| Infection Control: Urinary Tract Infection | Prevention of Nosocomial Urinary Tract Infections |
| Opioid Safety and Pain Management | Medication-Assisted Treatment |
| Pain Management | |
| Patient and Family Engagement | Advance Planning for End-of-Life Care |
| Cultural Competency | |
| Other Practices Related to Patient Participation | |
| Safety practices for hospitalized or institutionalized elders | Prevention of Delirium in Older Hospitalized Patients |
| Venous thromboembolism | Post-Surgical Prophylaxis Using Aspirin |
PSP = patient safety practice
Preliminary List of Patient Safety Practices (PSPs)
As shown in Figure 2, we identified 79 distinct PSPs that were considered further. Of these 79 PSPs, 23 were identified as having a low priority for review based on the preliminary assessment of the Evidence-based Practice Center (EPC) teams about the importance of the harm addressed by each PSP (in terms of the likelihood of harm from the condition and the scope of the condition addressed by the PSP, as described above). That left 56 PSPs on the list to be prioritized by the Technical Expert Panel (TEP) for inclusion in the MHS IV series of Rapid Reviews and Rapid Responses. Appendixes A and C provide details of the preliminary assessments of the PSPs including a description of each PSP, ratings of the prioritization criteria, and summative notes.
Final Prioritization of PSPs
As depicted in Figure 2, the TEP guided the final prioritization of topics. The initial TEP survey responses were used to create four categories of PSPs prior to the TEP meeting: excluded PSPs (any PSP with 7 or more votes to exclude), lower priority PSPs (PSPs with 5 to 7 votes to include), high-priority PSPs (PSPs with 11 or more votes to include), and PSPs targeted for TEP discussion and a second round of priority ratings (PSPs with “unsure” as the most common response, or 8 to 10 votes to include). PSPs categorized as excluded, lower priority, and high priority were not discussed in the TEP meeting. We focused on discussing the 29 PSPs with more uncertainty in the pre-meeting ratings. The TEP members reviewed the list of excluded, lower and high priority PSPs and were given the opportunity to discuss any PSPs they believed deserved further discussion. For each remaining PSP, the TEP reviewed a brief description of the PSP, EPC team assessments, and pre-survey TEP ratings to frame the discussion. As planned, after each PSP was discussed, the TEP members submitted their final votes about whether to include or exclude the PSP in the MHS IV series.
The final list of top priority PSPs is presented in Table 5 with additional supporting details in Appendix D. Based on the discussion with the TEP, we recommend that lower priority PSPs (including the TEP’s “write in” suggestions for PSPs which are listed in Appendix E) be reassessed later in the MHS IV process.
Figure 2. TEP prioritization process
EPC = Evidence-based Practice Center; MHS = Making Healthcare Safer; PSP(s) = Patient safety practice(s); TEP = technical expert panel
Table 5. Patient safety practices identified by the 15-member Technical Expert Panel as high priority for a Rapid Response, Rapid Review, or systematic review by the Making Healthcare Safer Team
| Patient Safety Practices | Recommendation |
|---|---|
| Antimicrobial stewardship | Systematic review |
| Handoff protocols | Rapid review |
| Opioid stewardship | Rapid review |
| Transmission-based precautions | Rapid review |
| Clinical decision support | Rapid review |
| Rapid response systems | Rapid review |
| Sepsis prediction, recognition, and intervention | Rapid review |
| Engaging family caregivers | Rapid review |
| Supply chain disruption | Rapid review |
| High reliability | Rapid review |
| Interventions to prevent non-ventilator–associated pneumonia for inpatients | Rapid review |
| Patient monitoring systems | Rapid response |
| Barcode verification | Rapid response |
| Implicit bias training | Rapid review |
| Post-event communication program | Rapid response |
| Protocols for high-risk drugs: reducing adverse drug events related to anticoagulants | Rapid response |
| Person and family engagement | Rapid response |
| Use of report cards and outcome measurements to improve safety of surgical care | Rapid response |
| Test result notification systems | Rapid response |
| Automated medication dispensing devices and dose drug distribution systems | Rapid response |
| Staff shortage | Rapid response |
| Deprescribing | Rapid response |
| Hours of service, fatigue, and sleepiness | Rapid response |
| Infection surveillance and testing | Rapid response |
| Performance review and feedback focused on diagnostic errors | Rapid response |
| Prevention of pressure ulcers in older patients | Rapid response |
| Capnography | Rapid review |
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Rosen M, Dy SM, Stewart CM, Shekelle P, Tsou A, Treadwell J, Sharma R, Zhang A, Vass M, Motala A, Bass EB. Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV. (Prepared by the Johns Hopkins, ECRI, and Southern California Evidence-based Practice Centers under Contract No. 75Q80120D00003). AHRQ Publication No. 23-EHC019-1. Rockville, MD: Agency for Healthcare Research and Quality. July 2023. DOI: https://doi.org/10.23970/AHRQEPC_MHS4PRIORITIZATION. Posted final reports are located on the Effective Health Care Program search page.
