Comparison Tables for Making Healthcare Safer Reports
The tables below compare all editions of the 大象视频鈥檚 Making Health Care Safer report.
The , published in 2001, was developed following the 1999 publication of , the seminal National Academy of Medicine report that elevated awareness of longstanding risks and patient harms occurring in the U.S. healthcare system. The inaugural report consisted of 50 patient safety practices in eight categories encompassing commonly occurring care and disease specific adverse events and associated systemic and contextual factors.
In 2013, 大象视频published a second edition of Making Health Care Safer. That report added new evidence-based safety practices while updating some practices with new evidence, and contained a total of 41 patient safety practices.
AHRQ鈥檚 third Making Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm areas. It includes evidence for more specific harm areas than the preceding reports.
The fourth Making Healthcare Safer report was commissioned in 2022 as a continuous updating of patient safety harms and practices. To address the emerging and evolving threats to patient safety, the advances in patient safety research, and the evolving accrediting body standards, this format intends to provide the most updated evidence-based information to aid healthcare organization leaders in facilitating adoption and implementation in a timelier way.
Taken together, the reports cover a wide range of patient safety practices. Methodologically, the practices (or PSPs) are similar but not identical. Following the first report, PSPs were included in subsequent reports if there was evidence for a new practice for improving patient safety or the topic was considered a pressing issue at the time of the report development. Subsequent reports also updated some PSPs of the previous report because there was new evidence available for the PSP or the topic was still considered a pressing issue for patient safety. Other PSPs were not updated because either there was no new evidence available or the topic was not considered a priority issue when the report was developed. For these reasons, a summary of evidence is not available for many PSPs. The cells indicating 鈥(Not reviewed)鈥 reflect that the topic was not reviewed and a summary of evidence is not available.
Although the methodology and context of collection of the patient safety practices of these three reports may vary, they serve as a consolidated source of evidence-based information for healthcare providers, health system administrators, researchers, and government agencies to use in patient safety improvement efforts.
- Adverse Drug Events (ADEs): General Medication Topics
- ADEs: Harms Due to Anticoagulants
- ADEs: Harms Due to Diabetic Agents
- ADEs: Reducing Adverse Drug Events in Older Adults
- ADEs: Harms Due to Opioids
- ADEs: Infusion Pumps
- Alarm Fatigue
- Care Transitions
- Cross-Cutting: Teamwork Training
- Cross-Cutting: Health Information Technology
- Cross-Cutting: Other Topics
- Delirium
- Diagnostic Errors
- Failure to Rescue
- General Clinical Topics
- Infection Control: Carbapenem-Resistant Enterobacteriaceae
- Infection Control: Central Line-Associated Bloodstream Infections
- Infection Control: Clostridioides difficile Infection
- Infection Control: Infections Due to Other Multidrug-Resistant Organisms
- Infection Control: Miscellaneous Topics
- Infection Control: Urinary Tract Infection
- Patient and Family Engagement
- Patient Identification Errors in the Operating Room
- Radiological
- Safety Practices for Hospitalized or Institutionalized Elders
- Sepsis Recognition
- Surgery, Anesthesia, and Perioperative Medicine
- Venous Thromboembolism
Adverse Drug Events (ADEs): General Medication Topics
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Computer Adverse Drug Event Detection and Alerts | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Unit-Dose Drug Distribution Systems | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Automated Medication Dispensing Devices | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Computerized Physician Order Entry With Clinical Decision Support Systems | (Not reviewed) | |||
| The Clinical Pharmacist's Role in Preventing Adverse Drug Events | (Not reviewed) | (Not reviewed) | ||
| Reducing Adverse Drug Events Related to Anticoagulants | (Not reviewed) | |||
| The Joint Commission鈥檚 鈥淒o Not Use鈥 List | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Medication Reconciliation Supported by Clinical Pharmacists | (Not reviewed) | (Not reviewed) | (Not reviewed) |
ADEs: Harms Due to Anticoagulants
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Single Provider | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Nomograms | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Medication Reconciliation and Handoffs | (Not reviewed) | (Not reviewed) | (Not reviewed) |
ADEs: Harms Due to Diabetic Agents
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Standardized Insulin Protocols | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Teach-Back | (Not reviewed) | (Not reviewed) | (Not reviewed) |
ADEs: Reducing Adverse Drug Events in Older Adults
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Deprescribing | (Not reviewed) | (Not reviewed) | ||
| Use of STOPP Criteria | (Not reviewed) | (Not reviewed) | (Not reviewed) |
ADEs: Harms Due to Opioids
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Opioid Stewardship | (Not reviewed) | (Not reviewed) | ||
| Medication-Assisted Treatment | (Not reviewed) | (Not reviewed) | (Not reviewed) |
ADEs: Infusion Pumps/Medication Error
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Smart Pumps and Other Protocols for Infusion Pumps | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Structured Process Changes/Workflow Redesign | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Staff Education and Training | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Alarm Fatigue
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Safety Culture | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Alarm Risk Assessment | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Care Transitions
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Structured Handoff Protocols for Intrahospital Transitions | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Interventions To Improve Care Transitions at Hospital Discharge | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| BOOST: Better Outcomes for Older Adults Through Safe Transitions | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| CTI: Care Transition Intervention | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| TCM: Transitional Care Model | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Cross-Cutting: Teamwork Training
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Crew Resource Management and its Applications in Medicine | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Teamwork and Team Training | (Not reviewed) | (Not reviewed) |
Cross-Cutting: Health Information Technology
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Video-Based Telehealth | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Information Transfer | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Clinical Decision Support | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Cross-Cutting: Other Topics
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Healthcare Worker Implicit Bias Training and Education | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Programs for Responding to Harms | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Supply Chain Disruption Monitoring Programs | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| "Closed" Intensive Care Units and Other Models of Care for Critically Ill Patients | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Fatigue, Sleepiness, and Medical Errors | (Not reviewed) | (Not reviewed) | ||
| Nurse Staffing, Models of Care Delivery, and Interventions | (Not reviewed) | |||
| Human Factors and Medical Devices | (Not reviewed) | (Not reviewed) | ||
| Promoting a Culture of Patient Safety | (Not reviewed) | |||
| Staff Education and Training (Simulation) | (Not reviewed) | |||
| Limiting Individual Provider鈥檚 Hours of Service | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Monitoring, Auditing, and Feedback | (Not reviewed) | (Not reviewed) |
Delirium
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Delirium in Older Hospitalized Patients | (Also listed under Safety Practices for Hospitalized or Institutionalized Elders) | (Also listed under Safety Practices for Hospitalized or Institutionalized Elders) | (Not reviewed) | (Not reviewed) |
| Screening and Assessment | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Staff Education and Training | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Nonpharmacologic Intervention Programs | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Diagnostic Error
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Patient Safety Practices Targeted at Diagnostic Errors | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Clinical Decision Support | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Performance Review and Feedback | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Result Notification Systems | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Staff Education and Training | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Failure To Rescue
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Rapid Response Systems | (Not reviewed) | |||
| Patient Monitoring Systems | (Not reviewed) | (Not reviewed) |
General Clinical Topics
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Safety During Transport of Critically Ill Patients | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Nutritional Support | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Pneumococcal Vaccination Prior to Hospital Discharge | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Pain Management | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients | (Not reviewed) | (Not reviewed) | ||
| Inpatient Intensive Glucose Control Strategies To Reduce Death and Infection | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Tubing Miscommunications | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Identifying Patients at Risk for Suicide | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Infection Control: Carbapenem-Resistant Enterobacteriaceae
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Transmission-Based Precautions: Contact Precautions, Patient Isolation, Dedicated Staff | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Infection Control: Central Line-Associated Bloodstream Infections
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Central Line-Associated Bloodstream Infections | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Interventions To Allow the Reuse of Single-Use Devices | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Infection Control: Clostridioides difficile Infection
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance | (Also listed in Vancomycin-resistant Enterococcus under Miscellaneous section) | (Not reviewed) | (Not reviewed) | (Not reviewed) |
| Antimicrobial Stewardship | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Testing | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Surveillance | (Not reviewed) | (Not reviewed) | ||
| Hand Hygiene | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Environmental Cleaning & Decontamination | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Multicomponent Prevention Interventions | (Not reviewed) | (Not reviewed) |
Infection Control: Infections Due to Other Multidrug-Resistant Organisms
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Hand Hygiene | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Surveillance | (Not reviewed) | (Not reviewed) | ||
| Minimize Use of Devices | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Chlorhexidine Bathing | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Communication of MDRO Status | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Environmental Cleaning & Disinfection | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Infection Control: Miscellaneous Topics
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Non-ventilator Hospital-Acquired Pneumonia | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance - Clostridium Difficile and Vancomycin-Resistant Enterococcus | (Also listed in Clostridium Difficile) | (Not reviewed) | (Not reviewed) | (Not reviewed) |
| Prevention of Ventilator-Associated Pneumonia | (Not reviewed) | (Not reviewed) | ||
| Practices To Improve Handwashing Compliance | Refer to and chapters | (Not reviewed) | ||
| Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections | Refer to MDROs (PDF, 2.7 MB) and chapters |
Infection Control: Urinary Tract Infection
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Nosocomial Urinary Tract Infections | (Not reviewed) | (Not reviewed) | ||
| Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections | (Not reviewed) | (Not reviewed) |
Patient and Family Engagement
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Engaging Family Caregivers With Structured Communication for Safe Care Transitions | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Advance Planning For End-of-Life Care | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Other Practices Related to Patient Participation | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Obtaining Informed Consent From Patients | (Not reviewed) | (Not reviewed) | ||
| Ensuring Documentation of Patients鈥 Preferences for Life-Sustaining Treatment | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Patient and Family Engagement | (Not reviewed) | |||
| Cultural Competency | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Patient Identification Errors in the Operating Room
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Misidentifications | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Operating Room/Surgery-Specific Practices | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Radiological
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Interventions To Prevent Contrast-Induced Acute Kidney Injury | (all patients) | (Not reviewed) | (Not reviewed) | |
| Preventing Patient Death or Serious Injury Associated With Radiation Exposure From Fluoroscopy and Computed Tomography | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Safety Practices for Hospitalized or Institutionalized Elders
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Multidisciplinary Geriatric Consultation Services | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Geriatric Evaluation and Management Units for Hospitalized Patients | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Prevention of Falls in Hospitalized and Institutionalized Older People | (all patients) | (Not reviewed) | (Not reviewed) | |
| Prevention of Pressure Ulcers in Older Patients | (all patients) | (Not reviewed) | (Not reviewed) | |
| Prevention of Delirium in Older Hospitalized Patients | (Also listed under Delirium) | (Also listed under Delirium) | Specific PSPs in Delirium chapter (PDF, 489 KB) | (Not reviewed) |
Sepsis Recognition
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Screening Tools and Algorithms | (Not reviewed) | (Not reviewed) | ||
| Patient Monitoring Systems | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Surgery, Anesthesia, and Perioperative Medicine
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Localizing Care to High-Volume Centers | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Learning Curves for New Procedures - the Case of Laparoscopic Cholecystectomy | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Prevention of Surgical Site Infections | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Ultrasound Guidance of Central Vein Catheterization | (Not reviewed) | (Not reviewed) | ||
| Prevention of Surgical Items Being Left Inside Patient | (Not reviewed) | (Not reviewed) | ||
| Pre-Anesthesia Checklists To Improve Patient Safety | (Not reviewed) | (Not reviewed) | ||
| The Impact of Intraoperative Monitoring on Patient Safety | (Not reviewed) | (Not reviewed) | (Not reviewed) | |
| Beta-blockers and Reduction of Perioperative Cardiac Events | (Not reviewed) | (Not reviewed) | ||
| Use of Report Cards and Outcome Measurements To Improve Safety of Surgical Care | (Not reviewed) | (Not reviewed) | ||
| Operating Room Integration and Display Systems | (Not reviewed) | (Not reviewed) | (Not reviewed) |
Venous Thromboembolism
| Patient Safety Practices | MHS I (2001) | MHS II (2013) | MHS III (2020) | MHS IV (2023-24) |
|---|---|---|---|---|
| Prevention of Venous Thromboembolism | (Not reviewed) | (Not reviewed) | ||
| Post-Surgical Prophylaxis Using Aspirin | (Not reviewed) | (Not reviewed) | (Not reviewed) |
