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Shojania KG, Duncan BW, McDonald KM, et al., editors. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Jul. (Evidence Reports/Technology Assessments, No. 43.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

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58Practices Rated by Research Priority

Further research on a number of practices would clarify a range of questions (eg, whether the practice is effective, what aspects of a multi-faceted intervention matter the most, how best to implement the practice). The conceptual framework for this categorization is described in Chapter 56. In Table 58.1 and 58.2, the practices are grouped in zones: "research likely to be highly beneficial," and "research likely to be beneficial." We also list, in the far-right column, the practices' categorization for "Strength of the Evidence" (as detailed above in Tables 57.1-57.5). For presentation in this table, this category is simplified into a 1 ("highest strength of evidence") to 5 ("lowest strength of evidence") which corresponds exactly to the groupings in Tables 57.1-5. We list these here to allow the reader to compare and contrast the research priority rankings with the evidence rankings. Practices that are not listed in either Table 58.1 or 58.2 may benefit from more research, but were not scored as highly as those included in these 2 lists.

Table 58.1 Further Research Likely to be Highly Beneficial.

Table

Table 58.1 Further Research Likely to be Highly Beneficial.

Table 58.2 Further Research Likely to be Beneficial.

Table

Table 58.2 Further Research Likely to be Beneficial.

Ch. #Patient Safety TargetPatient Safety PracticeImpactStudy StrengthEffect SizeVigilanceCostComplexity
6Medication errors and adverse drug events (ADEs) primarily related to ordering processComputerized physician order entry (CPOE) with clinical decision support system (CDSS)HighMedium 1 ModestMediumHigh 2 High
7Medication errors and ADEs related to ordering and monitoringClinical pharmacist consultation servicesHighMediumModest 3 LowHighLow
8ADEs related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)Use of computer monitoring for potential ADEsMediumMediumRobust 4 LowMedium 5 Low
9Adverse events related to anticoagulationProtocols for high risk drugs: nomograms for heparinMediumMedium 6 Robust 7 MediumLowLow
9Adverse events related to anticoagulationAnticoagulation services and clinics for coumadin 8 HighMediumUnclearLowMediumLow
9Adverse events related to chronic anticoagulation with warfarinPatient self-management using home monitoring devicesHighHighRobustMediumMedium 9 High 10
10ADEs in dispensing medicationsUnit-dosing distribution systemMedium 11 MediumUnclearLowLowLow
11ADEs in drug dispensing and/or administrationUse of automated medication dispensing devicesHighMedium 12 UnclearMediumMedium 13 Low
12Hospital-acquired infectionsImproved handwashing compliance (via education/behavior change; sink technology and placement; washing substance)HighMedium 14 Unclear 15 LowLowLow 16
13Serious nosocomial infections (eg, vancomycin-resistant enterococcus, C. difficile)Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel)HighMedium 17 RobustMedium 18 MediumLow 19
14Hospital-acquired infections due to antibiotic-resistant organismsLimitations placed on antibiotic useHigh 20 MediumModestMedium 21 LowLow
15.1Hospital-acquired urinary tract infectionUse of silver alloy-coated cathetersHighHighUnclear 22 LowLowLow
15.2Hospital-acquired urinary tract infectionUse of suprapubic cathetersHighHighUnclear 23 MediumHighHigh
16.1Central venous catheter-related blood infectionsUse of maximum sterile barriers during catheter insertionMediumHighRobustLowLowLow 24
16.2Central venous catheter-related blood infectionsAntibiotic-impregnated cathetersMediumHighRobustLow 25 LowLow
16.3Central venous catheter-related blood infectionsCleaning site (povidone-iodine to chlorhexidine)MediumHighUnclearLowLowLow
16.4Central venous catheter-related blood infectionsChanging catheters routinelyMediumHighNegligible± NAHighHigh
16.4Central venous catheter-related blood infectionsUse of heparinMediumHighUnclearMediumLowLow
16.4Central venous catheter-related blood infectionsTunneling short-term central venous cathetersMediumHighUnclearLowLowHigh
16.4Central venous catheter-related blood infectionsRoutine antibiotic prophylaxisMediumMediumNegligibleMediumMediumLow
17.1Ventilator-associated pneumoniaSemi-recumbent positioningHighMediumRobust 26 LowLowLow
17.1Ventilator-associated pneumoniaContinuous oscillationHighHighRobust 27 MediumMediumLow
17.2Ventilator-associated pneumoniaContinuous aspiration of subglottic secretions (CASS)HighHighRobust 28 LowLowHigh 29
17.3Ventilator-associated pneumoniaSelective decontamination of digestive tractHighHighRobust 30 Medium 31 LowLow
17.4Ventilator-associated pneumoniaSucralfateHighHighUnclearHigh 32 LowLow
18Mortality associated with surgical proceduresLocalizing specific surgeries and procedures to high volume centersHighMedium 33 VariesMediumVariesHigh
20.1Surgical site infectionsAppropriate use of antibiotic prophylaxisMedium 34 HighRobustMedium 35 LowLow
20.2Surgical site infectionsMaintenance of perioperative normothermiaHighMedium 36 RobustMedium 37 LowLow
20.3Surgical site infectionsUse of supplemental perioperative oxygenHighMedium 38 RobustLowLowLow
20.4Surgical site infectionsPerioperative glucose controlHighMediumRobustMediumLowHigh 39
21Morbidity due to central venous catheter insertionUse of real-time ultrasound guidance during central line insertionHighHighRobust 40 Low 41 MediumHigh
22Surgical items left inside patientCounting sharps, instruments, spongesInsuff. Info. 42 LowNot ratedNot ratedLowLow
23Complications due to anesthesia equipment failuresUse of preoperative anesthesia checklistsLow 43 LowNot ratedNot ratedLowLow
24Critical events in anesthesiaIntraoperative monitoring of vital signs and oxygenationLow 44 Medium 45 Unclear 46 LowLowLow
25Perioperative cardiac events in patients undergoing noncardiac surgeryUse of perioperative beta-blockersHighHighRobustMediumLowLow
26.1FallsUse of identification braceletsMediumMediumNegligibleLowLowLow
26.2Restraint-related injuries; FallsInterventions to reduce the use of physical restraints safelyMediumMediumUnclear 47 MediumMediumLow
26.3FallsUse of bed alarmsMediumMediumUnclearLow 48 Medium 49 Low
26.4Falls and fall-related injuriesUse of special flooring material in patient care areasMediumLowNot ratedNot ratedHighLow
26.5Falls and fall injuriesUse of hip protectorsMediumHighRobustMediumLow 50 Low 51
27Pressure ulcersUse of pressure relieving bedding materialsHighHighRobust 52 LowHighLow
28Hospital-related deliriumMulti-component delirium prevention programHighMediumRobustLowMediumLow
29Hospital-acquired complications (eg, falls, delirium, functional decline, mortality)Geriatric consultation servicesHighHighVaries 53 LowMediumHigh
30Hospital-acquired complications (functional decline, mortality)Geriatric evaluation and management unitHighHighModest 54 LowMediumHigh
31Venous thromboembolism (VTE)Appropriate VTE prophylaxisHighHighRobustMediumLowLow 55
32Contrast-induced renal failureUse of low osmolar contrast mediaMediumHighRobustLowHigh 56 Low
32Contrast-induced renal failureHydration protocols with theophyllineMediumHighNegligibleLowLowLow
32Contrast-induced renal failureHydration protocols with acetylcysteineMediumMedium 57 RobustLowLowLow
33Morbidity and mortality in post-surgical and critically ill patientsVarious nutritional strategiesHighHighRobust 58 MediumMediumLow
34Stress-related gastrointestinal bleedingH2-antagonistsMediumHighUnclearMedium 59 LowLow
35Clinically significant misread radiographs and CT scans by non-radiologistsEducation interventions and continuous quality improvement strategiesMediumMediumRobustLowLowLow
36Pneumococcal pneumoniaMethods to increase pneumococcal vaccination rateMediumHighUnclear 60 Low 61 LowLow
37.1Inadequate pain relief in hospital patients with abdominal painUse of analgesics in patients with acute abdomen without compromising diagnostic accuracyHighMedium 62 RobustMediumLowLow 63
37.2Inadequate pain reliefAcute pain serviceHighMediumRobust 64 Low 65 MediumLow
37.4Inadequate postoperative pain managementNon-pharmacologic interventions (eg, relaxation, distraction)HighHighUnclearLowLowLow
38Morbidity and mortality in ICU patientsChange in ICU structure -- active management by intensivistHighMediumRobust 66 LowMediumHigh
39Morbidity and mortalityChanges in nursing staffingHighMedium 67 VariesLowHighLow 68
40Any safety problem amenable to culturePromoting a culture of safetyInsuff. Info.** 69 VariesHigh
41.1Medical device related adverse eventsUse of human factors principles in evaluation of medical devicesInsuff. Info.** 70 VariesHigh
41.2Adverse eventsRefining performance of medical device alarms (eg, balancing sensitivity and specificity of alarms, ergonomic design)High 71 ** 72 VariesHigh
42.1Adverse events related to discontinuities in careInformation transfer between inpatient and outpatient pharmacyHighMediumRobustLowMedium 73 Low
42.2Adverse events during cross-coverageStandardized, structured sign-outs for physiciansMediumLowNot ratedNot ratedLow 74 Low
42.3Adverse events related to information loss at dischargeUse of structured discharge summariesInsuff. InfoLow 75 Not ratedNot ratedLowLow
42.4Failures to communicate significant abnormal results (eg, pap smears)Protocols for notification of test results to patientsMediumMediumModestLowLowLow
43.1Adverse events due to patient misidentificationUse of bar codingHigh 76 LowNot ratedNot ratedVaries 77 High
43.2Performance of invasive diagnostic or therapeutic procedure on wrong body part"Sign your site" protocolsHighLowNot ratedNot ratedLowHigh
44Adverse events related to team performance issuesApplication of aviation style crew resource management (eg, Anesthesia Crisis Management; MedTeams)High 78 LowNot ratedNot ratedMediumHigh
45Adverse events due to provider inexperience or unfamiliarity with certain procedures and situationsSimulator-based trainingInsuff. Info 79 Medium 80 Unclear 81 LowMediumLow
46Adverse events related to fatigue in health care workersLimiting individual provider's hours of serviceInsuff. Info.MediumUnclearLowHighHigh
46Adverse events related to fatigue in health care workersFixed shifts or forward shift rotationsInsuff. Info.** 82 Varies 83 Varies
46Adverse events related to fatigue in health care workersNapping strategiesInsuff. Info.** 84 High 85 Low
47Adverse events due to transportation of critically ill patients between health care facilitiesSpecialized teams for interhospital transportMediumMedium 86 ModestLowMediumLow
47Adverse events due to transportation of critically ill patients within a hospitalMechanical ventilationMediumMediumNegligibleLowLowLow
48Missed, incomplete or not fully comprehended informed consentAsking that patients recall and restate what they have been told during informed consentHighMediumRobustLowLowLow 87
48Missed, incomplete or not fully comprehended informed consentUse of video or audio stimuliHighMediumModestLowLow 88 Low
48Missed, incomplete or not fully comprehended informed consentProvision of written informed consent informationHighMediumUnclearLowLowLow
49Failure to honor patient preferences for end-of-life careComputer-generated reminders to discuss advanced directivesHighMediumRobustLowMedium 89 Low
49Failure to honor patient preferences for end-of-life careUse of physician order form for life-sustaining treatment (POLST)HighLowNot ratedNot ratedLowLow 90
±

Actually, studies show a detrimental effect of practice.

1

Medium strength of evidence for computerized physician order entry: although randomized control trials have been conducted, findings from sophisticated "home grown" systems only 2-3 sites may not be fully generalizable. In addition, the impact of the practice on adverse events has not been as well studied as for the non-clinical outcome, medication errors.

2

Cost of CPOE is substantially higher than for most other practices in the high cost category.

3

The impact of clinical pharmacists consultation services may be less than that of CPOE due to logistics of screening large volumes of orders to target those most prone to error or most consequential.

4

Estimate of effect size based on single study with limited target (only antibiotic treatments).

5

Cost influenced by whether existing computer systems are used in pharmacy services.

6

For nomogram protocols, study strength medium because the major concern (bleeding) is not addressed in most studies.

7

Effect size greater than 15% for surrogate markers; not bleeding or clot rate.

8

Anticoagulation clinics: Both inpatient and outpatient venues studied, so some heterogeneity among results.

9

Self-management of warfarin (coumadin): on average the cost per patient is low, but the aggregated cost is medium from the perspective of an insurer or integrated system.

10

Higher complexity of implementation because self-management practice displaces locus of control out of institution and may engender debate over insurance coverage. Other countries cover this practice, but it is currently not covered by Medicare in the United States.

11

Unit-dosing is a ubiquitous practice that has surprisingly little evidence of effectiveness; evidence is old and mixed.

12

Study strength is affected because outcomes measured are not the major outcomes of interest - ie, ADEs.

13

The implementation ratings are related to patient safety only, but note that institutions may also implement this practice for cost-savings due to less drug loss and better inventory control.

14

Study design for handwashing compliance practices generally had short duration of follow-up; no randomized control trials.

15

Unclear effect size due to mixed results and no clear pattern in a group of heterogeneous practices.

16

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

17

There are a number of studies of barrier precautions, but most are Level 3 study designs so the strength is not rated as "High."

18

Potential decrease in provider interaction with patients may cause psychological, as well as other, effects if care from clinicians is compromised.

19

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

20

Impact upgraded from "medium" to "high" rating because of public health impact of more antibiotic-resistant pathogens.

21

Practice requires active, ongoing monitoring and input from infection control officers to make sure proper drugs are prescribed. Also, vigilance includes need for institution-wide monitoring of pathogens.

22

The effect size of using silver alloy catheters is unclear: a well-done meta-analysis is positive, showing decrease in bacteriuria, but more recent results of possibly better designed individual studies are mixed regarding benefit. Also, the actual strength of the link, however intuitive, between bacteriuria and clinically significant urinary tract infection is unclear.

23

Effect size of using suprapubic catheters is unclear because of some heterogeneity in studies. Results are generally positive, but no meta-analysis yet conducted. In addition, the effect on outcome of clinically significant urinary tract infections is also unclear.

24

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

25

With antibiotic-impregnated catheters made with minocycline, there is the theoretical risk of increased antibiotic resistance.

26

Pneumonia outcome was significantly reduced, but mortality was not.

27

Meta-analysis of 6 randomized controlled trials showed significant and large relative risk reduction, but 2 other randomized controlled trials showed no impact.

28

Benefit observed in prevention of ventilator-acquired pneumonia; no established benefit for mortality.

29

High complexity for implementation since it requires retraining for a new practice.

30

Most benefit in reducing pneumonia and mortality occurs when both IV and topical decontamination are used. Topical (by itself) only reduces ventilator-associated pneumonia. However, topical carries less potential for harm (ie, antibiotic resistance).

31

Medium vigilance for harm because of public health concerns due to possible increase in antibiotic resistance. The Center for Disease Control and Prevention (CDC) and the American Thoracic Society (ATS) both recently reviewed this topic and did not recommend this practice.

32

If sucralfate were used because of its possible effect on reducing risk of ventilator-acquired pneumonia, it would displace a practice that has more established benefit for GI bleeding (H2 blockers).

33

The study strength for localizing care to high volume centers is evaluated across a range of practices. There are large variations in evidentiary base across specific practices. Evidence is not structured to determine effect on patient safety. Although the literature includes possible benchmarks/thresholds for volume levels for specific procedures, the evidence is related more to quality enhancement than to improvements in patient safety.

34

Relatively high current utilization of practice reduced impact by one level.

35

Vigilance is required to monitor antibiotic overuse to prevent negative public health effects.

36

Study strength is rated as medium because randomized clinical trial data only applies to one disease process, although may be generalizable.

37

Medium vigilance for harm: although not studied, for certain cohorts the practice may be detrimental.

38

Study strength is rated as medium because randomized clinical trial data only applies to one disease process, although may be generalizable.

39

Tight perioperative glucose control requires major shift in practice style, increased vigilance, more coordination between nurses and physicians, and perhaps new policies regarding nursing care for diabetics.

40

Effect size high, but more impressive decrease in "failed insertion attempts" than in more clinically relevant complications. Also, there is some heterogeneity in study results, and there are two different technologies assessed (plain ultrasound vs. US with doppler), and the results vary.

41

Theoretical risk that additional manipulation/handling could increase infection risk; also concern regarding impact on providers' abilities to place catheters emergently when ultrasound guidance is not available.

42

Insufficient information about retained sponges: the event is highly concerning and often morbid when occurs, but the only data on frequency are from case reports.

43

Low potential impact because anesthesia complications are already so uncommon; also difficult to determine impact of current use of some version of this practice (eg, low opportunity possible due to current utilization).

44

Low potential impact because anesthesia complications are already so uncommon; also difficult to determine impact of current use of some version of this practice (eg, low opportunity possible due to current utilization).

45

Although there has been a very large randomized trial of pulse oximetry, other studies covered additional aspects of intraoperative monitoring and were generally of lower study design quality.

46

Pulse oximetry study showed no benefit, but major potential methodologic problems, such as secular trends. Complications that monitoring are designed to find are very unusual, so even a large trial may have been under-powered to detect important effects.

47

Because the patient safety target is reduction of unnecessary restraints, there are multiple outcomes of interest. Although reducing unnecessary restraints does not seem to increase the risk of falls, it raises other concerns regarding disconnected IVs, elopement risk, etc., which have not been fully evaluated.

48

Probably low, as categorized, but there is a theoretical risk that patients will not receive as much attention from nurses and other providers.

49

Medium cost based on relatively widespread implementation of bed alarms required to impact all patients who may potentially benefit. May also impact nursing workload and staffing needs.

50

Possibly higher cost if large numbers of patients would benefit from wearing hip protectors. There is also the question of whether these costs are borne by system/insurers or patients themselves.

51

Implementation complexity in the hospital may be low, but implementation outside of the hospital might involve large educational campaign directed at patients who could benefit from practice.

52

Studies compare a variety of special bedding materials to standard beds. Effect size for one special bed option versus another is not known. Unclear which particular surface works best.

53

Effect size varies since heterogeneous outcomes, perhaps in part related to the variety of interventions, some of which involved both inpatient and outpatient components.

54

Effect size varies due to heterogeneous results, which depend in part on the outcomes of interest (ie, functional outcomes vs. mortality).

55

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

56

Total cost, of course, depends on the extent of utilization (eg, all patients versus only targeted patients). Cost-effectiveness analyses demonstrate the importance of targeting appropriate patients.

57

Outcome is level 2, only one study for N-acetylcystine.

58

Varies according to specific nutritional support practice. Robust findings for early enteral nutrition in critically ill and post-surgical patients.

59

Vigilance for harm is medium because of potential risk of increasing ventilator-associated pneumonia, and also because of possible overuse since high-risk groups are now better defined.

60

Depends on specific intervention; standing orders have the highest effectiveness.

61

Harm concern low, except one recent study (see Chapter 36) showed trend toward harm in HIV-positive patients.

62

Although some studies were randomized control trials, they did not look at all clinically relevant outcomes to ensure that practice was safe. Under-powered to assess whether diagnostic capability not impaired.

63

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

64

Only studied for post-operative pain; may not apply more generally.

65

Some speculation that care may be fragmented when applied broadly, beyond post-operative patients.

66

Some of the positive results may be attributable to factors other than the intervention. Concern about underlying population changing (eg, secular trends).

67

Study strength is medium despite a number of studies, because of variation in practices (eg, various measures of nurse staffing, models of care). Chapter was designed to generalize across practices regarding nursing structure versus outcomes; evidence is not structured to tell effect on patient safety, and there are no benchmarks/thresholds for nurse staffing levels.

68

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

69

Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-health care industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the health care literature.

70

Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-health care industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the health care literature.

71

Although alarms are ubiquitous in the hospital, it is unclear how many adverse events might be improved by improvements in alarm systems.

72

Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-health care industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the health care literature.

73

Costs are shared among a variety of payors including outpatient pharmacy.

74

Cost would vary based on interventions considered -- some low-tech, paper-based, or pocket computers; higher cost for full-scale computerized systems.

75

Although one randomized trial performed, the outcomes reported were only indirectly related to patient safety outcomes.

76

Somewhat unclear, but errors due to misidentification can be grave.

77

Cost varies based on specific system and level of implementation.

78

Impact is a function of how widely the practice can be used (ICU vs. ward teams vs. operating room).

79

Insufficient information outside of anesthesia about volume of human factors errors amenable to training approaches.

80

Limited studies with small numbers of participant and with different simulators lead to concerns about generalizability.

81

Effect unclear since few studies with comparable simulators, and evaluated with mostly Level 3 outcomes.

82

Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-health care industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the health care literature.

83

Fixed shift may be more costly and difficult to implement than forward rotation.

84

Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-health care industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the health care literature.

85

Restructuring patient care to allow for napping while minimizing discontinuities could be expensive.

86

Study strength is borderline-medium with three Level 3 studies.

87

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

88

Cost for video disks - assumes that off-the-shelf products exist for common procedures; would be higher if an institution has to build its own systems.

89

Cost would be lower for health care organizations that already rely on computers for care management.

90

Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

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