The Patient Safety Primers developed by the Agency for Healthcare Research & Quality (AHRQ) should be a prime source of information and advice for risk managers when seeking to solve problems. That is the view of Barbara Youngberg, a risk expert for insurance and risk management brokerage Beecher Carlson.
“While it is true that more sophisticated data collection systems and reporting protocols help to identify problems in US healthcare organizations, fixing problems remains a challenge,” she said
“Most of the time, evidence-based information is required to convince others to change and that there is a better way to address problems. Even though the problem can seem so complex and deeply rooted that risk management and patient safety professionals don’t know where to start, many of the most vexing issues in healthcare have already been identified and solved. There is often no need to reinvent the wheel if solid, evidence-based solutions are available.”
The Agency for Healthcare Research & Quality (AHRQ) is under the umbrella of Health and Human Services (HHS), whose mission it is to produce evidence to make healthcare safer, higher quality, more accessible, equitable and affordable.
The AHRQ also works with the US Department of Health and Human Services, as well as with other partners, to understand and utilize the evidence.
“The information provided by AHRQ is designed to benefit consumers of healthcare, practitioners of healthcare and policy makers,” said Youngberg. “Patient Safety Organizations (PSO’s) are operated under the auspices of AHRQ and much of the patient safety work product (PSWP) collected and analyzed under the PSO program is used to understand patient safety problems and systemic vulnerabilities.”
This data has also led to many research studies being funded and the production of tool kits, she added. These provide detailed policies, procedures and practices that other organizations have developed and successfully used to bring about change in their own organizations. Evolving from this, AHRQ implemented the Patient Safety and Quality Improvement Act that shares this information and includes the oversight of the PSO organizations.
“AHRQ has continued to develop valuable resources detailing common patient safety problems and solutions,” she said. “These Patient Safety Primers are available through the PSNet portal. They not only cover a broad range of topics, but also provide detailed and varied levels of support.
“Once you access the PSNet site you will see summaries of recent journal articles that can be used to support changes that you are trying to make in your organization. If you click on the tab identified as ‘Patient Safety Primers’, you will find a collection of comprehensive tool kits on a variety of topics.”
Each primer provides detailed information about the topic and provides solutions for addressing the problem. In addition, there are multiple references relevant to the topic which can be useful when preparing a literature review as part of an RCA or FMEA, which your organization might be developing for an external regulatory agency.
“Accessing these tools should be the first step a risk manager or patient safety officer takes when assigned to work on an organizational patient safety problem,” she said.
Barbara Youngberg, Beecher Carlson, Agency for Healthcare Research & Quality, US
