about high-risk conditions and patients, thus opening the door to preventive interventions. The committee believes that continued evolution along these three dimensions is critical and that steps should be taken to accelerate the pace of this evolution. All health care settings, not just hospitals, nursing homes, and large group practices, should have mature patient safety systems and cultures.

Recommendation 5. All health care settings should establish comprehensive patient safety programs operated by trained personnel within a culture of safety. These programs should encompass (1) case finding—identifying system failures, (2) analysis—understanding the factors that contribute to system failures, and (3) system redesign—making improvements in care processes to prevent errors in the future. Patient safety programs should invite the participation of patients and their families and be responsive to their inquiries.

Efforts should also be made to develop a rich portfolio of knowledge and tools that will be useful to all health care settings seeking to establish comprehensive patient safety systems. Research in this area should focus on the development of the full range of data-driven trigger systems for the detection and prevention of adverse events. Additional research is also needed to assist health care settings in establishing effective reporting systems for near misses. As noted above, the health care sector has far less experience with such systems than with those focusing on adverse events. The high volume and diversity of reports submitted to near-miss systems pose certain challenges.

Recommendation 6. The federal government should pursue a robust applied research agenda on patient safety, focused on enhancing knowledge, developing tools, and disseminating results to maximize the impact of patient safety systems. AHRQ should play a lead role in coordinating this research agenda among federal agencies (e.g., the National Library of Medicine) and the private sector. The research agenda should include the following:

  • Knowledge generation

  • High-risk patients—Identify patients at risk for medication errors, nosocomial infections, falls, and other high-risk events.

  • Near-miss incidents—Test the causal continuum assumption (that near misses and adverse events are causally related), develop and test a recovery taxonomy, and extend the current



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