AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century

AHRQ's Making Healthcare Safer reports consolidate information for healthcare providers, health system administrators, researchers, and government agencies about practices that can improve patient safety across the healthcare system—from hospitals to primary care practices, long-term care facilities, and other healthcare settings.

Despite sustained national attention and successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries each year. These reports provide information the field needs to evaluate how to prioritize efforts to keep patients safe. The reports also will benefit researchers by helping them easily identify where more research is needed and will assist policymakers in understanding which patient safety practices have supporting evidence to be promoted and adopted widely.

The first Making Health Care Safer report, published in 2001, was developed following the 1999 publication of To Err is Human: Building a Safer Health System, the seminal National Academy of Medicine report that elevated awareness of longstanding risks and patient harms occurring in the U.S. healthcare system. The inaugural report consisted of 50 patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse events and associated systemic and contextual factors.

In 2013, AHRQ published a second edition of Making Health Care Safer. That report added new evidence-based safety practices while updating some practices with new evidence, and contained 41 patient safety practices. 

AHRQ's third Making Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm areas. It includes evidence for more specific harm areas than the preceding reports.

The fourth Making Healthcare Safer report was commissioned in 2022 as a continuous updating of patient safety harms and practices. To address the emerging and evolving threats to patient safety, the advances in patient safety research, and the evolving accrediting body standards, this format intends to provide the most updated evidence-based information to aid healthcare organization leaders in facilitating adoption and implementation in a timelier way.

A set of tables compares the patient safety practices among the reports.