A recent Agency for Healthcare Research and Quality (AHRQ) report, “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices,” holds nearly 1,000 pages of practice-management tips for improving outcomes. But where does a hospitalist begin when reviewing such a massive playbook for progress?
Jim Battles, PhD, an AHRQ social science analyst for patient safety who worked on the report, says the best place to start is by asking yourself: “What keeps you up at night? … What scares the heck out of you?”
The report, a follow-up to the influential and controversial 2001 report “Making Health Care Safer: A Critical Analysis of Patient Safety Practices,” is viewed by its authors as the next step in the continuum of improving patient outcomes. The latest research culled a list of more than 100 patient-safety practices (PSPs) down to 10 that should be “strongly encouraged” and another dozen that are “encouraged.” Battles looks at the 2001 report as more about pushing physicians to think about PSPs, with the updated version as a guidebook on how to think about it.
—Jim Battles, PhD, an AHRQ social science analyst for patient safety, co-author of new AHRQ report
Paul Shekelle, MD, PhD, director of the Southern California Evidence-Based Practice Center site of RAND Corp., which AHRQ commissioned to produce the report, says that some might look at safety initiatives since the landmark Institute of Medicine report “To Err is Human” in 1999 and question whether enough progress has been made. But all progress is meaningful to individual patients, and the improvements of the past decade and a half have been important, he adds.
“What I believe is that we’ve made a lot of progress in certain areas,” Dr. Shekelle says, “but this can't be seen when we look at aggregate data, because the improvements we have seen don't account for a sufficiently large proportion in aggregate of the overall patient safety problem.”
Dr. Shekelle—one of three co-principal investigators on the report, along with Peter Pronovost, MD, PhD, FCCM, of Johns Hopkins School of Medicine in Baltimore and HM pioneer Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco—says he hopes physicians realize that while the report’s recommendations are evidence-based, they’re not a magic bullet.
“One of the main messages of our report is this is not like writing a prescription for a statin,” Dr. Shekelle says. “This is going to take work. It’s going to take local adaptation, and it’s going to take talking to your front-line clinicians to try and find out how to make this thing work.”
Dr. Wachter, who helped craft both the 2001 and 2013 reports, says patient safety “can be one of those things that is so compelling and so dramatic that you develop a little bit of Nike syndrome—let’s just do it, let’s just computerize, let’s just do teamwork training, let’s do simulation.” However, the healthcare system has a much better, deeper understanding of patient safety and “the role of context, the role of the setting, the role of collateral interventions. It’s generally not going to be one thing that’s the magic bullet, but it’s going to be one thing embedded in a series of other activities that are designed to make sure that you have the right design and the right culture.”
Drs. Wachter and Shekelle and Battles agree that much of the difficulty with patient safety practices is rooted in healthcare system cultures. Each uses different terms to describe the roadblock, as Dr. Wachter discusses implementation science and Battles highlights the difference between the technical work of PSPs and their “social adoption.” But all concur that unless PSPs are committed for the long haul, implementation might be little more than lip service.
“It’s a responsibility of the CEO, the CMO, the CNO, and environmental services, all the way down,” Battles says. “You have to develop around these practices the shared ownership of the risk you’re trying to mitigate. Otherwise, this list of practices, OK, it’s a nice list. But you’ve got to say, ‘What are the risks and hazards to my organization, and how can I apply these evidence practices to the problem?’” TH
Richard Quinn is a freelance writer in New Jersey.
10 Recommendations for Hospitalists
The following patient-safety practices (PSPs) were dubbed “strongly encouraged” in the AHRQ evidence report:
- Preoperative checklists and anesthesia checklists to prevent operative and post-operative events.
- Bundles that include checklists to prevent central-line-associated bloodstream infections.
- Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
- Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
- Hand hygiene.
- “Do Not Use” list for hazardous abbreviations.
- Multicomponent interventions to reduce pressure ulcers.
- Barrier precautions to prevent healthcare-associated infections (HAIs).
- Use of real-time ultrasound for central line placement.
- Interventions to improve prophylaxis for VTE.