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Research: At the Heart of Patient Safety Improvement

Posted By Administration, Friday, August 12, 2016
Updated: Friday, August 12, 2016

The National Patient Safety Foundation has joined with 250 other organizations in the Friends of AHRQ
to voice our support for the agency and its mission.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


As noted in the recent NPSF report Free from Harm, the scientific process does not always move in a straight line. This can be illustrated by conflicting studies. For example, in a 2009 paper, Haynes and colleagues demonstrated a benefit from the use of surgical safety checklists. Several years later, Urbach and others were not able to replicate the results.


Researchers wisely recognize that the latter studies illustrate the need for both safety science research (the development of the checklist) and implementation science research (how best to put them into use). Because of this, one of the NPSF report’s eight recommendations to accelerate patient safety calls for increased research funding for both safety science and implementation research.


Since 1999, the U.S. Agency for Healthcare Research and Quality (AHRQ), has played an essential role in funding, conducting, and sharing results of patient safety research. A section of the federal Department of Health & Human Services, AHRQ was created by Congress with the purpose of “producing evidence to make health care safer; higher quality; more accessible, equitable, and affordable; and to ensure that the evidence is understood and used.”


In addition to compiling the National Healthcare Quality and Disparities Reports, AHRQ has funded and helped promulgate numerous evidence-based tools and resources. Among these are the Comprehensive Unit-Based Safety Program (CUSP), which is now being used in hospitals throughout the country; Team STEPPS®, developed in collaboration with the Department of Defense to improve teamwork in clinical settings; and the new CANDOR Toolkit, which provides a roadmap for organizations to learn how to communicate with patients about medical errors and adverse events.

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My own entrée to the patient safety field was as a researcher with a focus on ambulatory safety and the use of technology to improve quality and safety. AHRQ funded key research that my colleagues and I conducted on missed and delayed diagnosis errors and their causes, and the impact of barcode technology on medication safety, among many other topics. This critical research really helped advance our understanding of ambulatory safety and the benefits of technology. And it likely would never have happened without AHRQ providing the funding.


Regrettably, AHRQ recently saw its budget reduced to $280.24 million, a $54 million reduction from current levels, even though the AHRQ budget has historically represented less than 1% of all federally funded research. (See AHRQ: 15 Years of Transforming Care and Improving Health.) The National Patient Safety Foundation has joined with 250 other organizations in the Friends of AHRQ, which is being led by Academy Health, a leading health services research organization, to voice our support for the agency and its mission.


Now is not the time to reverse course in patient safety research. We need to expand patient safety research throughout all health settings if we are going to continue to make progress in ensuring safety care.


To read more about the NPSF report Free from Harm and the tactics recommended for increasing research funding, visit   Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  AHRQ  research 

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