The Government Accountability Office (GAO) has issued a report focusing on the roadblocks hospitals face in implementing evidence-based patient safety practices, such as the use of antiseptics to reduce Central Line-Associated Bloodstream Infection or administration of anti-clotting medications to higher-risk patients to prevent venous thromboembolism. Based on a review of selected hospitals, the OIG found that hospitals experience challenges related to:

  1. Obtaining data to identify adverse events in their own hospitals, since substantial time and resources are required to gather the necessary data.
  2. Determining which patient safety practices should be implemented, since in some cases only limited evidence exists on effectiveness.
  3. Ensuring that staff consistently implement the practices over time.

Hospitals reported that overcoming these challenges involved dedicating resources to patient safety efforts and systematically involving hospital management, physicians, and staff in patient safety efforts. The OIG also interviewed patient safety experts and reviewed literature, which identified gaps where better information could help hospitals. Such information includes: (1) the effects of contextual factors (e.g., organizational characteristics) on the implementation of patient safety practices in different hospitals, (2) details on the experiences of and strategies used by hospitals that have implemented patient safety practices, and (3) improved techniques for measuring the frequency of certain adverse events. For details, see the full report, “Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.”