Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Executive Summary. Evidence Report/Technology Assessment Number 211.

摘要

The 1999 Institute of Medicine report To Err is Human: Building a Safer Health System, is credited by many with launching the modern patient safety movement. A year after this report was published, as part of its initial portfolio of patient safety activities, the Agency for Healthcare Research and Quality (AHRQ) commissioned a group from the University of California, San Francisco-Stanford Evidence-based Practice Center (EPC) to analyze evidence behind a diverse group of patient safety practices (PSPs) that existed at that time. The resulting 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, hereafter referred to as Making Health Care Safer, was both influential and controversial. A significant number of copies of the report were distributed by AHRQ, and it became a cornerstone of other efforts (such as the National Quality Forums 34 Safe Practices for Better Healthcare list)3 to rank safety practices by strength of evidence. However, the low rankings given to some popular safety practices, such as computerized order entry, raised fundamental questions about the role of evidence-based medicine in quality and safety practices. Since the Making Health Care Safer report was published, the safety field has matured. Regulators and accreditors encourage health care organizations to adopt safe practices and to avoid adverse events that are considered wholly or largely preventable.