Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices, Report to Congressional Requesters [open pdf - 1018KB]
From the Highlights: "While millions of Americans benefit from the medical care they receive each year, this care also has the potential to harm patients. Medical care can be unsafe when it leads to adverse events, such as infections. Such adverse events occur even though evidence indicates that some could be reduced or eliminated through implementation of evidence-based patient safety practices. GAO [Government Accountability Office] was asked to review information on the implementation of patient safety practices in hospitals. This report describes (1) key factors that affect hospitals' implementation of evidence-based patient safety practices and their reported effects on adverse events; (2) the types of programs health care payers use to promote hospital patient safety and their reported effects on adverse events; and (3) gaps, if any, that experts identify in the available information on patient safety practices. GAO interviewed patient safety experts and officials from six selected hospitals, six selected insurers, and officials from CMS [Centers for Medicare & Medicaid Services] and AHRQ [Agency for Healthcare Research and Quality]. GAO selected the hospitals based in part on their performance on certain quality measures related to patient safety and selected the insurers because they operated relevant patient safety programs. The information GAO obtained on the hospitals and insurers is not generalizable. GAO also reviewed literature on the field of patient safety research. In commenting on a draft of this report, HHS [Department of Health and Human Services] generally agreed with GAO's findings. GAO also received technical comments from HHS and incorporated them as appropriate."
U.S. Government Accountability Office: http://www.gao.gov/