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Ideas and Opinions |

Advancing the Science of Patient Safety

Paul G. Shekelle, MD, PhD; Peter J. Pronovost, MD, PhD; Robert M. Wachter, MD; Stephanie L. Taylor, PhD; Sydney M. Dy, MD, MSc; Robbie Foy, MSc, MBChB; Susanne Hempel, PhD; Kathryn M. McDonald, MM; John Ovretveit, PhD; Lisa V. Rubenstein, MD, MSPH; Alyce S. Adams, PhD; Peter B. Angood, MD; David W. Bates, MD; Leonard Bickman, PhD; Pascale Carayon, MD; Sir Liam Donaldson, MD; Naihua Duan, PhD; Donna O. Farley, PhD; Trisha Greenhalgh, MD; John Haughom, MD; Eileen T. Lake, PhD, RN; Richard Lilford, PhD; Kathleen N. Lohr, PhD; Gregg S. Meyer, MD, MSc; Marlene R. Miller, MD, MSc; Duncan V. Neuhauser, PhD; Gery Ryan, PhD; Sanjay Saint, MD, MPH; Kaveh G. Shojania, MD; Stephen M. Shortell, PhD; David P. Stevens, MD; and Kieran Walshe, PhD
[+] Article and Author Information

From RAND Health, Santa Monica, California, and Pittsburgh, Pennsylvania; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; The Johns Hopkins University, Baltimore, Maryland; University of California, San Francisco, San Francisco, California; University of Leeds, Leeds, United Kingdom; Stanford University, Stanford, California; Karolinska Institutet, Stockholm, Sweden; Kaiser Permanente, Oakland, California; National Quality Forum, Washington, DC; Harvard Medical School and Massachusetts General Physicians Organization, Boston, Massachusetts; Vanderbilt University, Nashville, Tennessee; University of Wisconsin–Madison, Madison, Wisconsin; Department of Health and University College London, London, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth, Bellevue, Washington; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; University of Birmingham, Birmingham, United Kingdom; RTI International, Research Triangle Park, North Carolina; Case Western Reserve University, Cleveland, Ohio; University of Michigan, Ann Arbor, Michigan; University of Toronto, Toronto, Ontario, Canada; University of California, Berkeley, Berkeley, California; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and The University of Manchester, Manchester, United Kingdom.


Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the AHRQ. Therefore, no statement in this report should be construed as an official position of the AHRQ or the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank Lauren Carr, MPH; Breanne Johnsen, MPH; Patricia Smith; and Aneesa Motala.

Grant Support: By the AHRQ (contract HHSA-290-2009-10001C).

Potential Conflicts of Interest: Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2776.

Requests for Single Reprints: Paul G. Shekelle, MD, PhD, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401; e-mail, shekelle@rand.org.

Current Author Addresses: Drs. Shekelle, Taylor, Hempel, and Ryan: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401.

Dr. Pronovost: The Johns Hopkins University, Second Floor, 1209 Thames Street, Baltimore, MD 21231.

Dr. Wachter: University of California, San Francisco, Box 0120, San Francisco, CA 94143-0120.

Dr. Dy: Health Services Research and Development Center, The Johns Hopkins University, 624 North Broadway, Room 609, Baltimore, MD 21205-1901.

Dr. Foy: Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, Yorks LS2 9LJ, United Kingdom.

Ms. McDonald: Stanford University, 117 Encina Commons, Stanford, CA 94305.

Dr. Ovretveit: Medical Management Centre, Floor 5, Berzelius Väq 3, Karolinska Institutet, Stockholm, SE-171 77, Sweden.

Dr. Rubenstein: Veterans Affairs Greater Los Angeles Healthcare System, Sepulveda Campus, 16111 Plummer Street, North Hills, CA 91343.

Dr. Adams: Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.

Dr. Angood: National Quality Forum, 601 13th Street NW, Suite 500 North, Washington, DC 20005.

Dr. Bates: Division of General Internal Medicine, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02115.

Dr. Bickman: Vanderbilt University's Peabody College, Peabody #151, 230 Appleton Place, Nashville, TN 37203-5721.

Dr. Carayon: Department of Industrial & Systems Engineering, College of Engineering, University of Wisconsin–Madison, 3126 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706.

Sir Donaldson: National Patient Safety Agency, 44 Butler's and Colonial Wharf, London SE1 2PX, United Kingdom.

Dr. Duan: Division of Biostatistics, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 48, New York, NY 10032.

Dr. Farley: RAND Institute, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213.

Dr. Greenhalgh: Healthcare Innovation and Policy Unit, Centre for Health Sciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, Abernethy Building, 2 Newark Street, London E1 2AT, United Kingdom.

Dr. Haughom: PeaceHealth, 14432 SE Eastgate Way, Suite 300, Bellevue, WA 98007-6412.

Dr. Lake: University of Pennsylvania School of Nursing, Room 302 Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217.

Dr. Lilford: Birmingham Clinical Research Academy, Room 110, 90 Vincent Drive, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.

Dr. Lohr: RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.

Dr. Meyer: Massachusetts General Physicians Organization, 55 Fruit Street, Boston, MA 02114.

Dr. Miller: The Johns Hopkins University, 200 North Wolfe Street, Baltimore, MD 21287.

Dr. Neuhauser: Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106.

Dr. Saint: University of Michigan, 300 NIB, Room 7E08, Ann Arbor, MI 48109-0429.

Dr. Shojania: Sunnybrook Health Sciences Center, University of Toronto, Room H468, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.

Dr. Shortell: School of Public Health, University of California, Berkeley, 50 University Hall, Berkeley, CA 94720.

Dr. Stevens: Dartmouth Institute for Health Policy and Clinical Practice, 30 Lafayette Street, Lebanon, NH 03766.

Dr. Walshe: Harold Hankins Building-Room 6.36, Manchester Business School, The University of Manchester, Manchester M13 9PL, United Kingdom.

Author Contributions: Conception and design: P.G. Shekelle, P.J. Pronovost, R.M. Wachter, S.L. Taylor, R. Foy, K.M. McDonald, L.V. Rubenstein, A.S. Adams, P.B. Angood, D.W. Bates, L. Bickman, T. Greenhalgh, J. Haughom, E.T. Lake, R. Lilford, K.N. Lohr, G.S. Meyer, M.R. Miller, D.V. Neuhauser, G. Ryan, S. Saint, K.G. Shojania, S.M. Shortell, D.P. Stevens, K. Walshe.

Analysis and interpretation of the data: P.G. Shekelle, P.J. Pronovost, S.L. Taylor, S.M. Dy, R. Foy, S. Hempel, J. Ovretveit, L.V. Rubenstein, P.B. Angood, L. Bickman, D.O. Farley, J. Haughom, E.T. Lake, G.S. Meyer, M.R. Miller, D.V. Neuhauser, S. Saint, K.G. Shojania, S.M. Shortell.

Drafting of the article: P.G. Shekelle, P.J. Pronovost, S.M. Dy, R. Foy, J. Ovretveit, L. Bickman, G.S. Meyer, G. Ryan, K. Walshe.

Critical revision of the article for important intellectual content: P.G. Shekelle, P.J. Pronovost, R.M. Wachter, S.M. Dy, R. Foy, S. Hempel, K.M. McDonald, N. Duan, D.O. Farley, L.V. Rubenstein, A.S. Adams, P.B. Angood, D.W. Bates, T. Greenhalgh, J. Haughom, E.T. Lake, R. Lilford, K.N. Lohr, G.S. Meyer, M.R. Miller, G. Ryan, S. Saint, K.G. Shojania, D.P. Stevens, K. Walshe.

Final approval of the article: P.G. Shekelle, P.J. Pronovost, R.M. Wachter, S.L. Taylor, S.M. Dy, R. Foy, S. Hempel, K.M. McDonald, J. Ovretveit, L.V. Rubenstein, N. Duan, D.O. Farley, A.S. Adams, P. Carayon, L. Donaldson, P.B. Angood, D.W. Bates, L. Bickman, T. Greenhalgh, J. Haughom, E.T. Lake, R. Lilford, K.N. Lohr, G.S. Meyer, M.R. Miller, G. Ryan, S. Saint, K.G. Shojania, S.M. Shortell, D.P. Stevens.

Provision of study materials or patients: P.J. Pronovost, L.V. Rubenstein.

Statistical expertise: P.J. Pronovost, N. Duan, D.V. Neuhauser.

Obtaining of funding: P.G. Shekelle, P.J. Pronovost, R. Foy, L.V. Rubenstein.

Administrative, technical, or logistic support: P.J. Pronovost, S.L. Taylor, L. Donaldson.

Collection and assembly of data: P.G. Shekelle, P.J. Pronovost, S.L. Taylor, S.M. Dy, S. Hempel, J. Ovretveit, L.V. Rubenstein, G.S. Meyer, M.R. Miller, S.M. Shortell.


Ann Intern Med. 2011;154(10):693-696. doi:10.7326/0003-4819-154-10-201105170-00011
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Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

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