In 1999 the Institute of Medicine's report To Err Is Human: Building a Safer Health System delivered this bombshell. "Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. " The report defined medical errors" as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."
Fast-forward, a relative term given the time it takes research findings to translate into clinical practice, and the Agency for Healthcare Research and Quality identifies ten patient s...
AHRQ's Top 10 Patient Safety Strategies
preoperative and anesthesia checklists to reduce operative and postoperative events;
bundles including checklists to reduce septicemia associated with central lines;
catheter reminders, stop orders, nurse-initiated removal protocols, and other interventions to limit urinary catheter use;
bundles to prevent ventilator-associated pneumonia, including head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes;
do-not-use list for hazardous abbreviations;
multicomponent interventions to help prevent pressure ulcers;
barrier precautions to reduce healthcare-associated infections;
central line placement guided by real-time ultrasonography; and
strategies to improve venous thromboembolism prophylaxis.
Excerpt from "AHRQ Identifies Top 10 Patient Safety Strategies" by Laurie Barclay, MD, Medscape News, 3/4/2013