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Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices

, M.D., M.S., , Ph.D., Pharm.D., , M.P.H., M.A., , M.P.H., , M.H.S., , M.P.H., , M.S., , M.A., , M.D., , Dr.P.H., C.P.P.S., , Ph.D., M.S.W., , M.P.H., , Ph.D., , M.S.W., M.P.H., , , M.S.P.H., , M.P.P., , Pys.D., , Ph.D., M.B.A., , M.P.H., , M.P.H., , R.N., D.N.P., , Ph.D., R.N., and .

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 20-0029-EF

Structured Abstract


To review and summarize the evidence for selected patient safety practices (PSPs) and factors important to their successful implementation and adoption.

Data sources:

Searches of computerized databases for articles in peer-reviewed publications and in the gray literature.


The full project team took part in some or all of the following six-step report process:

  1. Development of conceptual framework
  2. Identification, selection, and prioritization of harm area topics
  3. Identification, selection, and prioritization of patient safety practices
  4. Literature searches
  5. Review of the evidence
  6. Report development
To conduct the literature searches, the project team identified PSP-specific search terms and ran them for every PSP in the MEDLINE and CINHAL databases, filtering for English publications only between 2008 and 2018. Across the PSPs examined, there was wide variation in the rigor of studies included in the evidence reviews. Individual authors decided the minimum threshold of quality for including specific studies given the state of the field for each PSP. We aimed to apply the criteria drawn from the Evidence-based Practice Center “Methods Guide for Effectiveness and Comparative Effectiveness Reviews” on strength of evidence derived from GRADE. To the extent possible, authors for each review indicated the strength of evidence by practice, outcome, and/or setting.


The five major threats to safety that were addressed include medication management issues, healthcare-associated infections, nursing sensitive events, procedural events, and diagnostic errors; and the report covers 47 PSPs in 17 specific harm areas. The PSPs were chosen for inclusion in the report based on the high-impact harms they address and interest in the status of their appropriateness for use. While the team was going through the process of selecting PSPs to address specific harm areas, it became evident that several cross-cutting contextual factors should also be reviewed. These cross-cutting practices are improving safety culture; teamwork and team training; clinical decision support; person and family engagement; cultural and linguistic competency; staff education and training; and data monitoring, audit, and feedback.


The amount of published research in patient safety has exponentially grown since the last AHRQ “Making Health Care Safer” report was published in 2013, albeit with publications varying in quality. PSPs that are more well-established are now being investigated in light of emerging harms, such as the applicability of infection-prevention-related PSPs to address the threat from multidrug-resistant organisms. Similarly, emerging PSPs are being investigated for use to address well-established harms, such as the use of clinical decision support to reduce diagnostic errors. It is clear that a wide range of factors impact the effectiveness of PSPs with respect to their ability to prevent harm.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857; www.ahrq.gov Contract No. 233-2015-00013-I Prepared by: Abt Associates Inc., Rockville, MD

Suggested citation:

Hall KK, Shoemaker-Hunt S, Hoffman L, Richard S, Gall E, Schoyer E, Costar D, Gale B, Schiff G, Miller K, Earl T, Katapodis N, Sheedy C, Wyant B, Bacon O, Hassol A, Schneiderman S, Woo M, LeRoy L, Fitall E, Long A, Holmes A, Riggs J, Lim A. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. (Prepared by Abt Associates Inc. under Contract No. 233-2015-00013-I.) AHRQ Publication No. 20-0029-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2020.

This project was funded under contract/grant number Contract No. 233-2015-00013-I, Task Order #HHSP23337002T from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this product as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this product.

This product is made publicly available by AHRQ and may be used and reprinted without permission in the United States for noncommercial purposes, unless materials are clearly noted as copyrighted in the document. No one may reproduce copyrighted materials without the permission of the copyright holders. Users outside the United States must get permission from AHRQ to reprint or translate this product. Anyone wanting to reproduce this product for sale must contact AHRQ for permission.

Bookshelf ID: NBK555526PMID: 32255576


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