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This report presents the results of a two-year study carried out under a contract with the Agency for Healthcare Research and Quality (AHRQ), which documents and analyzes the extent to which patient safety practices are being adopted by U.S. health care providers, examines hospital experiences with AHRQ's patient safety culture survey, and assesses trends in patient safety outcomes. The focus was on local initiatives to establish effective patient safety practices in the hospital, ambulatory care, and long-term care sectors. Successful implementation of these actions should lead to improved practices by providers and fewer adverse events for patients. Researchers also interviewed hospitals that use AHRQ's patient safety culture survey to learn their experiences with it. They performed case studies of patient safety activities in four communities: Indianapolis, Indiana; Cleveland, Ohio; Seattle, Washington; and Greenville, South Carolina. They also studied the dynamics of patient safety activities by hospitals in those communities and gathered information on how they adopted specific safe practices. Despite the progress observed, more work is needed to develop tools and measures for patient safety in the ambulatory care and long-term care sectors, as well as to establish a national capability to monitor changes in patient safety infrastructure, practices, and effects on a variety of involved stakeholders.

Table of Contents

  • Chapter One

    Introduction and Background

  • Chapter Two

    Uptake of Patient Safety Practices in Four U. S. Communities

  • Chapter Three

    Use of the Hospital Survey on Patient Safety Culture

  • Chapter Four

    National Survey on Adoption of NQF Safe Practices

  • Chapter Five

    Trends for Patient Safety Outcomes

  • Chapter Six

    Suggested Approach for Monitoring Effects of the Patient Safety Initiative

  • Appendix A

    Boundary Spanners Interviewed In the Community Study

  • Appendix B

    Case Studies from the Community Study

  • Appendix C

    Summary of Results from Roundtable Discussions on NQF Safe Practices

  • Appendix D

    NQF Safe Practices Not Included in Survey

  • Appendix E

    Final Version of the Survey

  • Appendix F

    Rationale for Design of the Survey Items

This work was sponsored by the Agency for Healthcare Research and Quality (AHRQ). The research was conducted in RAND Health, a division of the RAND Corporation.

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