Table 1.

AHRQ’s Suggested Practice for Decreasing of nursing homes and home care
Hospitalization, Critical Care, or Surgery agencies (CMS 2003; Clancy and
1. Prophylaxis to prevent venous thromboembolism in patients at Scully 2003).
risk In 2001, the Agency for Healthcare
2. Use of perioperative beta-blockers in appropriate patients Research and Quality (AHRQ)
3. Use of maximum sterile barriers when placing central venous distributed a document, entitled
catheters
“Making Healthcare Safer,” that lists 73
4. Appropriate use of prophylactic antibiotics in surgical patients
interventions that are likely to improve
5. Asking patients to recall and restate information received
during the informed consent process patient safety. From the 73 items,
6. Continuous aspiration of subglottic secretions to prevent AHRQ identified 11 that are proven to
ventilator-associated pneumonia be highly effective but that are not
7. Use of pressure-relieving bedding materials to prevent pressure routinely employed by practitioners
ulcers
(see Table 1) (Shojania et al. 2001).
8. Use of real-time ultrasound guidance when placing central
venous catheters AHRQ also developed a web-based,
9. Patient self-management for warfarin to achieve appropriate peer-reviewed medical journal that
outpatient anticoagulation presents medical error cases for
10. Appropriate provision of nutrition in critically ill and surgical discussion and in-depth analysis.
patients
These two governmental initiatives
11. Use of antibiotic-impregnated central venous catheters to
reduce infection represent an excellent starting point
for healthcare executives to audit their
If healthcare institutions do not take own institutional practices and to
a more aggressive posture, many of engage physicians in evidence-based
these non-healthcare organizations are improvement efforts.
likely to supplant them in advancing
the agenda of quality and patient National Quality Forum
safety. The National Quality Forum (NQF
2002) is a private, not-for-profit
Governmental Safety Initiatives organization whose mission is to
In 2000, the U.S. Department of improve American healthcare through
Health and Human Services (HHS) endorsement of consensus-based
developed the Patient Safety Task national standards for measurement
Force to coordinate all and public reporting of healthcare
intergovernmental activities related to performance data (Quality Forum
the collection of patient safety data. 2003). The NQF completed a report,
HHS also now reports on the quality entitled “Serious Reportable Events in

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