Table A-4Patient Safety Practices with Lower Impact and/or Strength of Evidence *


Item

Patient Safety Problem

Patient Safety Practice

Implementation Cost/Complexity

48

Central venous catheter-related bloodstream infections

Cleaning site (povidone-iodine to chlorhexidine) (Ch. 16.3)

Low

49

Central venous catheter-related bloodstream infections

Use of heparin (Ch. 16.4)

Low

50

Central venous catheter-related bloodstream infections

Tunneling short-term central venous catheters (Ch. 16.4)

Medium

51

Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)

Geriatric consultation services (Ch. 29)

High

52

Inadequate pain relief in patients with abdominal pain in hospital patients

Use of analgesics in the patient with acute abdomen without compromising diagnostic accuracy (Ch. 37.1)

Low

53

Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations

Simulator-based training (Ch. 45)

Medium

54

Adverse drug events (ADEs) in drug dispensing and/or administration

Use of automated medication dispensing devices (Ch. 11)

Medium

55

Hospital-acquired infections

Improve handwashing compliance (via education/behavior change; sink technology and placement; washing substance) (Ch. 12)

Low

56

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

Use of physician order form for life-sustaining treatment (POLST) (Ch. 49)

Low

57

Adverse events due to patient misidentification

Use of bar coding (Ch. 43.1)

Medium (Varies)

58

Adverse drug events (ADEs) in dispensing medications

Unit-dosing distribution system (Ch. 10)

Low

59

Critical events in anesthesia

Intraoperative monitoring of vital signs and oxygenation (Ch. 24)

Low

60

Adverse events during cross-coverage

Standardized, structured sign-outs for physicians (Ch. 42.2)

Low

61

Adverse events related to team performance issues

Applications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) (Ch. 44)

High

62

Adverse events related to fatigue in health care workers

Limiting individual providerÆs hours of service (Ch. 46)

High
*

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

Cover of AHRQ Evidence Report Summaries
AHRQ Evidence Report Summaries.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.