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Cover of Making Health Care Safer

Making Health Care Safer

A Critical Analysis of Patient Safety Practices

Evidence Reports/Technology Assessments, No. 43

Edited by Kaveh G Shojania, MD, Bradford W Duncan, MD, Kathryn M McDonald, MM, Robert M Wachter, MD, and Amy J Markowitz, JD, Managaging Editor.

Editor Information

Edited by Kaveh G Shojania, MD,1 Bradford W Duncan, MD,2 Kathryn M McDonald, MM,2 Robert M Wachter, MD,1 and Amy J Markowitz, JD, Managaging Editor.

1 UCSF
2 Stanford
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 01-E058

Structured Abstract

Objectives:

Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety.

Search Strategy and Selection Criteria:

Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts.

Data Collection and Analysis:

Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities.

Main Results:

Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation: appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; use of maximum sterile barriers while placing central intravenous catheters to prevent infections; appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; asking that patients recall and restate what they have been told during the informed consent process; continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; use of pressure relieving bedding materials to prevent pressure ulcers; use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin™) to achieve appropriate outpatient anticoagulation and prevent complications; appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

Conclusions:

An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.

Contents

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Project Director: Robert M Wachter, MD. UCSF-Stanford EPC Coordinator: Kathryn M McDonald, MM.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-97-0013. Prepared by: University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center.

Suggested citation:

Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California at San Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-0013), AHRQ Publication No. 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care, and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

1

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Bookshelf ID: NBK26966
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