What Practices Will Most Improve Safety?

convertedanissueofgrowingprofessionalaware-ness to one of substantial public concern in a mannerandpaceunprecedentedinmodernexperiencewithmattersof health care quality. The epidemiologic finding that morethan 1 million injuries and nearly 100000 deaths occur inthe United States annually as a result of mistakes in medicalcare came from studies nearly a decade old, but it was newinformationforthepublic,anditresonatedstrongly.Inshortorder, the US Congress initiated hearings and the presidentordered a government-wide feasibility study, which led to asubsequent directive to governmental agencies to imple-menttherecommendationsoftheIOMreport.TheIOMcalledonallpartiestomakeimprovingpatientsafetyanationalpri-ority. In response, physicians, hospitals, and health care or-ganizations have been searching for safe practices and ask-ing what they should do to make health care safer.Anticipating this need, the IOM report also recom-mendedthattheAgencyforHealthcareResearchandQual-ity (AHRQ) determine which safety practices are effectiveand disseminate a list of “best practices” to all clinicians.Responding to this appeal, AHRQ requested the NationalQuality Forum to use a consensus process of experts to de-fine a list of best practices. To inform this process, it alsocommissioned the Evidence-Based Practice Center (EPC),University of California, San Francisco–Stanford Univer-sity, to evaluate the evidence supporting a long list of pro-posedsafetypractices.Givena6-monthtimeframe,theEPCenlistednumerousexpertsnationwidetoconducttheanaly-ses. The resulting report by Shojania and colleagues