Assessment of the AHRQ Patient Safety Initiative

The Agency for Healthcare Research and Quality (AHRQ) has been carrying out its congressional mandate to establish a patient-safety research and development initiative to help health care providers reduce medical errors and improve patient safety. In September 2003, AHRQ entered into a four-year contract with the RAND Corporation to serve as the patient safety evaluation center for its patient safety initiative. The evaluation center is responsible for performing a longitudinal evaluation of the full scope of AHRQ’s patient safety activities and for providing regular feedback to support the continuing improvement of this initiative over the four-year project period.

This report covers the period October 2004 through September 2005. It is the third of what will be four annual reports prepared by RAND during the formative evaluation. It builds on two preceding evaluation reports, which covers the periods October 2003 through September 2004 and October 2004 through September 2005. This report updates the policy context framing the AHRQ patient safety initiative, documents the evolution and current status of priorities and activities undertaken in the initiative, assesses contributions of newly awarded health information technology projects to the broader initiative, and tracks dissemination actions AHRQ has taken to support adoption of evidence-based safe practices. Implications of the evaluation findings are discussed with respect to future AHRQ policy, programming, and research, and suggestions are presented for strengthening AHRQ’s future activities in the initiative. The annual evaluation reports are designed to provide a stable structure for the longitudinal evaluation, with the results of each year’s assessment contributing to a cumulative record of the initiative’s progress.

The contents of this report will be of interest to national and state policymakers, health care organizations and clinical practitioners, patient-advocacy organizations, health researchers, and others with responsibilities for ensuring that patients are not harmed by the health care they receive.