What practices will most improve safety? Evidence-based medicine meets patient safety.

THE INSTITUTE OF MEDICINE (IOM) REPORT TO ERR IS HUman converted an issue of growing professional awareness to one of substantial public concern in a manner and pace unprecedented in modern experience with matters of health care quality. The epidemiologic finding that more than 1 million injuries and nearly 100000 deaths occur in the United States annually as a result of mistakes in medical care came from studies nearly a decade old, but it was new information for the public, and it resonated strongly. In short order, the US Congress initiated hearings and the president ordered a government-wide feasibility study, which led to a subsequent directive to governmental agencies to implement the recommendations of the IOM report. The IOM called on all parties to make improving patient safety a national priority. In response, physicians, hospitals, and health care organizations have been searching for safe practices and asking what they should do to make health care safer. Anticipating this need, the IOM report also recommended that the Agency for Healthcare Research and Quality (AHRQ) determine which safety practices are effective and disseminate a list of “best practices” to all clinicians. Responding to this appeal, AHRQ requested the National Quality Forum to use a consensus process of experts to define a list of best practices. To inform this process, it also commissioned the Evidence-Based Practice Center (EPC), University of California, San Francisco–Stanford University, to evaluate the evidence supporting a long list of proposed safety practices. Given a 6-month time frame, the EPC enlisted numerous experts nationwide to conduct the analyses. The resulting report by Shojania and colleagues is a superb and ground-breaking compendium of what is known about the evidence of effectiveness for certain topics of interest in the science of preventing complications. Where practical, these practices should be implemented. Evidence-based assessment, as conducted by the EPC, is a formal method of literature analysis that uses standardized techniques and places heavy emphasis on data from randomized controlled trials. Advocates of evidence-based medicine (EBM) argue that medical decisions should be based, as much as possible, on a firm foundation of highgrade scientific evidence, rather than on experience or opinion. The motivation for EBM stems from the observation that many widely used practices lack supporting evidence and are therefore of questionable value. In the past, many experience-based and opinion-based practices have proved to be ineffective or even harmful. For patient safety practices, to our knowledge, no thorough, evidence-based assessment of the literature had been performed previously. Thus, the publication of Evidence Report 43 in July 2001 was eagerly anticipated by health care leaders who are anxious to improve safety but not sure what to do. However, to their surprise and confusion, many found that a number of the improvements in safety practice they have been working so hard to implement are not even mentioned in the report (TABLE). Furthermore, of the 11 practices Shojania et al recommend most highly as “clear opportunities for safety improvement” because they met the formal criteria for strength of evidence regarding impact and effectiveness, only 3 have been usually characterized as safety issues at all: anticoagulation for prevention of deep venous thrombosis, antibiotic prophylaxis to prevent surgical infections, and use of pressure-relieving materials to prevent pressure ulcers.