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Reducing medical errors: Federal report outlines ways to improve patient safety


Healthcare organizations must make learning new methods to improve safety a constant process. Staff, patients and families should offer input.

As healthcare organizations strive to improve patient care, experts say it’s critical to reduce medical errors.

The U.S. Department of Health and Human Services recently published a report on reducing medical errors. The Agency for Healthcare Research and Quality, the federal agency charged with improving safety in medical care, contributed to the report. The report was required by the Patient Safety Act of 2005.

The report outlines a host of factors healthcare organizations need to consider. Here’s a rundown of some of the key findings.

Analytic approaches

Healthcare organizations should use analytic approaches in examining patient safety research and practice improvement. This includes how and why some processes are successful and how to monitor risk.

Better base

More research is needed to develop an evidence base on patient safety. “Expanding the use of research methodologies that explore and capture the complexity of patient safety problems and solutions will also advance the evidence base,” the report stated.

Lifelong learning

The report said organizations must embrace the idea of becoming “learning health systems.” Healthcare organizations must continue to improve measures to boost patient safety and understand that it will be an ongoing process of learning new and better practices. By becoming learning health systems, organizations can improve patient safety and also make progress in providing better care, gaining more efficiency, and closing gaps in health inequities, the report stated.

Learning health systems  “have leaders who are committed to a culture of continuous learning and improvement. They have systems in place to gather and apply evidence in real time to guide care. They have the capacity to share new evidence and support clinician decisionmaking in (healthcare information technology).”

Keep it real

It’s not enough to identify strong, evidenced-based practices. They have to be put in place in real-world settings, the report stated. That requires developing the right tools and infrastructure. It also involves bringing about changes in the culture of a healthcare organization, with better communication and leadership. Policies should be developed with the input of key players who will be most affected, the report stated.

Adopt National Action Plan

The National Steering Committee for Patient Safety issued the National Action Plan in 2020 that can advance measures to improve the safety of patients and reduce medical errors. That plan recommended steps including establishing competencies for all health care professionals; getting input from patients, families, and government partners in safety efforts; and developing shared safety goals.

National Academy of Medicine guidance

The National Academy of Medicine reviewed the report and outlined some of its own recommendations in an appendix.

The NAM recommended funding for demonstration projects to illustrate the benefits of patient safety organizations. To lower reporting costs, the NAM also called for developing strategies to advance automated transmission of patient safety information from electronic health records. And the academy suggested utilizing artificial intelligence to compare information from large sets of data.

More information

Looking for more tips to improve patient safety? The AHRQ has outlined the top ten tips for patient safety tips for hospitals. They include improving the hospital discharge process to ensure patients know how to take medications and other steps to follow; preventing bloodstream infections from central lines; and educating patients about blood thinners, among others.

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