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Patient safety
The end of the beginning: the strategic approach to patient safety research
  1. G S Meyer,
  2. J M Eisenberg
  1. Centre for Quality Improvement and Patient Safety, Rockville, MD 20852, USA
  1. Correspondence to:
 Dr G S Meyer, Director, Centre for Quality Improvement and Patient Safety, 6011 Executive Boulevard, Suite 200, Rockville, MD 20852, USA;
 gmeyer{at}ahrq.gov

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Research into patient safety has undergone a period of rapid acceleration since the decision of the US AHRQ to make a specific commitment to fund research into systems for improving patient safety

Patient safety is not a new issue and has been the subject of research internationally for decades. Funding for patient safety in the US has been around for some time and, in fact, work cited in the Institute of Medicine (IOM)'s landmark report1 was funded by the Agency for Healthcare Research and Quality (AHRQ). Supported research has investigated preventable adverse drug events,2 the role of systems failures in the aetiology of medical errors,3 and the effects of the healthcare workforce on safety.4 Other funding in Australia and the UK has advanced our knowledge of patient safety considerably.

The funding of these important studies, however, was not based on any strategic commitment to addressing the patient safety challenge but, instead, the approach of research funders to patient safety had been an opportunistic one. The agencies solicited bright patient safety researchers employing sound methodology to address compelling issues. Funding was awarded on the basis of the ability to compete successfully against a wide range of healthcare issues. As a result, the number of researchers involved, the armamentarium of methodologies, and the scope of the research has been relatively limited.

BACKGROUND

In 1999 the US AHRQ made the decision to take a different, more strategic approach to patient safety research. The Agency's fiscal year 2000 budget included a specific commitment to fund research in patient safety through a modest $2 million investment in research on systems related best practices in improving patient safety.5 It was hoped that this initial foray into funding patient safety research would slowly evolve into a sustained initiative which would gradually grow in terms of both importance and investment.

The IOM report,1 however, dramatically changed the deliberate but slow transition to a more strategic approach in funding patient research in the US. The report highlighted the urgent need to develop an evidentiary base for safety improvement through research. In response to the IOM report, the President asked the federal government's Quality Interagency Coordination Task Force (QuIC) to draft a comprehensive plan to address the issues of medical errors and patient safety.6 Both the IOM and QuIC reports called for a substantial targeted investment in patient safety research which became a reality with the appropriation of $50 million for patient safety research in AHRQ's fiscal year 2001 budget.

“Be careful what you wish for”

The myriad of challenges in affecting the strategic transformation of patient safety research have, at times, suggested the adage of “be careful what you wish for . . .”. Because patient safety research was not a new field, agenda setting and the mechanisms to support research had to be cognisant of its history. Existing literature from the safety field, for example, demonstrated the value of a multidisciplinary approach to patient safety research demanding novel tactics to promote multidisciplinary teams of researchers. The relative paucity of funding had led to a situation where there were relatively few established researchers in the field. To meet this challenge the new strategy to funding patient safety research had to ensure an adequate funding stream for those investigators while cultivating new researchers to build future capacity.

Finally, and most importantly, it was made clear by the Congress and the public that elegant research papers in prestigious journals were not an adequate deliverable for the public investment in patient safety research. The research investment strategy had to be crafted in a manner which maximised the likelihood that the results of the research would be rapidly and effectively translated and disseminated into widespread practice. To meet that challenge, AHRQ—together with public, private, and international partners (UK, Australia)—held a unique agenda setting summit in September 2000. The summit represented a dramatic shift from traditional research agenda setting which relied on the opinions of expert researchers who were asked “what is the cutting edge of this research field?”. Instead, the patient safety research summit took a user's perspective where groups that would use the products of patient safety research—including patients, providers, plans, purchasers, and policy makers—were asked “what are the questions which could be addressed with research which you could use to make health care safer?” This agenda (box 1) has become a touchstone for AHRQ and many of its partners.7

Box 1 Research areas (identified in the September 2000 summit)

  • Epidemiology of errors

  • Infrastructure to improve patient safety

  • Information systems

  • Performance shaping factors

  • Evidence based interventions

  • Safety cultural issues

  • Educational tools

Transforming patient safety research into a strategic priority also required the development of novel approaches to funding research. Investment in patient safety research by AHRQ in 2001 used a portfolio of six complementary research solicitations effectively to address the varied needs of the users of patient safety research with five distinct priorities: (1) to increase our understanding of what is working in patient safety reporting, (2) to support established and developing multidisciplinary teams to generate new knowledge to enhance patient safety, (3) to examine the role of working conditions and performance shaping factors on patient safety, (4) to evaluate information technology based interventions to improve patient safety, and (5) to promote the dissemination of the results of this research through educational programmes. Contracts to plan future work on improving patient safety data systems, develop systems based measures of patient safety, and a coordinating centre whose aim is to ensure that the whole of the investment in patient safety research is much greater than the sum of its parts are other important components of the portfolio.

The implementation of the AHRQ's patient safety agenda faced a number of significant logistical challenges including the evaluation of methodological approaches which were often unfamiliar to traditional health services researchers, difficulties in developing review panels with sufficient expertise (because most established investigators responded to the research solicitations and were conflicted), and trying to judge which applications showed the greatest promise in impacting safety in the absence of standardised approaches to measurement.

Despite all of these challenges, the quantity and quality of applications to research solicitations exceeded all expectations, and much was learned about the variety of approaches which can be applied to patient safety research. The resulting portfolio of research represents an opportunity to make a quantum leap in the evidentiary base of patient safety improvement (the AHRQ website (www.ahrq.gov) has a complete listing of the grants funded under the patient safety research initiative).

WHERE ARE WE TODAY AND WHERE MUST WE GO?

The patient safety research community has much to be proud of. There is a previously unimagined support for the field, exciting new research projects and teams, international interest and, now, a new journal dedicated to reporting these exciting findings and programmes. But significant responsibilities have come with these opportunities. The momentum for patient safety research can only be maintained if the promises made are indeed kept. The research community must not only produce an enhanced evidentiary base for safety improvement, but must also ensure that these results are translated into practice.

The transformation to a strategic approach to patient safety research has undergone a period of rapid acceleration. We have reached the end of the beginning. Funding agencies around the world are looking at the US strategic approach to funding patient safety. It is rare for a research paradigm to evolve in real time, and it is incumbent upon the patient safety research community to ensure that this transformation is sustained and not ephemeral. Continued support for patient safety research demands a return on investment. Producing great research is not enough, we must improve safety. We owe it to our patients and the public.

Research into patient safety has undergone a period of rapid acceleration since the decision of the US AHRQ to make a specific commitment to fund research into systems for improving patient safety

REFERENCES

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Footnotes

  • The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Agency for Healthcare Research and Quality, and the Department of Health and Human Services.

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