Table A-5Patient Safety Practices with Lowest Impact and/or Strength of Evidence*


Item

Patient Safety Problem

Patient Safety Practice

Implementation Cost/Complexity

63

Complications due to anesthesia equipment failures

Use of pre-anesthesia checklists (Ch. 23)

Low

64

Adverse events related to information loss at discharge

Use of structured discharge summaries (Ch. 42.3)

Low

65

Surgical items left inside patients

Counting sharps, instruments and sponges (Ch. 22)

Low

66

Ventilator-associated pneumonia

Use of sucralfate (Ch. 26.4)

Low

67

Falls and fall-related injuries

Use of special flooring material in patient care areas (Ch. 26.4)

Medium

68

Performance of invasive diagnostic or therapeutic procedure on wrong body part

"Sign your site" protocols (Ch. 43.2)

Medium

69

Falls

Use of identification bracelets (Ch. 26.1)

Low

70

Contrast-induced renal failure

Hydration protocols with theophylline (Ch. 32)

Low

71

Adverse events due to transportation of critically ill patients within a hospital

Mechanical rather than manual ventilation during transport (Ch. 47)

Low

72

Central venous catheter-related bloodstream infections

Changing catheters routinely (Ch. 16.4)

High

73

Central venous catheter-related bloodstream infections

Routine antibiotic prophylaxis (Ch. 16.4)

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

Cover of AHRQ Evidence Report Summaries
AHRQ Evidence Report Summaries.

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