Table A-3 Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness *


Item

Patient Safety Problem

Patient Safety Practice

Implementation Cost/Complexity

26

Medication errors and adverse drug events (ADEs) primarily related to ordering process

Computerized physician order entry (CPOE) and clinical decision support (CDSS) (Ch. 6)

High

27

Failures to communicate significant abnormal results (e.g., pap smears)

Protocols for notification of test results to patients (Ch. 42.4)

Low

28

Adverse events due to transportation of critically ill patients between health care facilities

Specialized teams for interhospital transport (Ch. 47)

Medium

29

Medication errors and adverse drug events (ADEs) related to ordering and monitoring

Clinical pharmacist consultation services (Ch. 7)

Medium

30

Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)

Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) (Ch. 13)

Medium

31

Surgical site infections

Perioperative glucose control (Ch. 20.4)

Medium

32

Stress-related gastrointestinal bleeding

H2 antagonists (Ch. 34)

Low

33

Pneumococcal pneumonia

Methods to increase pneumococcal vaccination rate (Ch. 36)

Low

34

Inadequate pain relief

Acute pain service (Ch. 37.2)

Medium

35

Adverse events related to anticoagulation

Anticoagulation services and clinics for coumadin (Ch. 9)

Medium

36

Hospital-acquired infections due to antibiotic-resistant organisms

Limitations placed on antibiotic use (Ch. 14)

Low

37

Hospital-acquired urinary tract infection

Use of suprapubic catheters (Ch. 15.2)

High

38

Contrast-induced renal failure

Hydration protocols with acetylcysteine (Ch. 32)

Low

39

Clinically significant misread radiographs and CT scans by non-radiologists

Education interventions and continuous quality improvement strategies (Ch. 35)

Low

40

Missed or incomplete or not fully comprehended informed consent

Provision of written informed consent information (Ch. 48)

Low

41

Failure to honor patient preferences for end-of-life care

Computer-generated reminders to discuss advanced directives (Ch. 49)

Medium (Varies)

42

Adverse events related to anticoagulation

Protocols for high-risk drugs: nomograms for heparin (Ch. 9)

Low

43

Ventilator-associated pneumonia

Continuous oscillation (Ch. 17.1)

Medium

44

Surgical site infections

Maintenance of perioperative normothermia (Ch. 20.2)

Low

45

Restraint-related injury; Falls

Interventions to reduce the use of physical restraints safely (Ch. 26,2)

Medium

46

Falls

Use of bed alarms (Ch. 26.3)

Medium

47

Contrast-induced renal failure

Use of low osmolar contrast media (Ch. 32)

Medium
*

Items within a particular category are not necessarily in rank order. Items are for reference only.

Abbreviations: Ch. = Chapter

From: 43, Making Health Care Safer: Summary

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AHRQ Evidence Report Summaries.

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