Table 58.2 Further Research Likely to be Beneficial

ChapterPatient Safety TargetPatient Safety PracticeImpact/ Evidence Category (1-5)
17.2Ventilator-associated pneumoniaContinuous aspiration of subglottic secretions (CASS)1
17.1Ventilator-associated pneumoniaSemi-recumbent positioning2
26.5Falls and fall injuriesUse of hip protectors2
30Hospital-acquired complications (functional decline, mortality)Geriatric evaluation and management unit2
47Adverse events due to transportation of critically ill patients between health care facilitiesSpecialized teams for interhospital transport3
34Stress-related gastrointestinal bleedingH2-antagonists3
37.2Inadequate pain reliefAcute pain service3
15.2Hospital-acquired urinary tract infectionUse of suprapubic catheters3
26.2Restraint-related injury; FallsInterventions to reduce the use of physical restraints safely3
45Adverse events due to provider inexperience or unfamiliarity with certain procedures and situationsSimulator-based training4
49Failure to honor patient preferences for end-of-life careUse of physician order form for life-sustaining treatment (POLST)4
42.2Adverse events during cross-coverageStandardized, structured sign-outs for physicians4
44Adverse events related to team performance issuesApplications of aviation-style crew resource management (eg, Anesthesia Crisis Management; MedTeams)4
16.2Central venous catheter-related bloodstream infectionsAntibiotic-impregnated catheters1
17.3Ventilator-associated pneumoniaSelective decontamination of digestive tract2
42.4Failures to communicate significant abnormal results (eg, pap smears)Protocols for notification of test results to patients3
36Pneumococcal pneumoniaMethods to increase pneumococcal vaccination rate3
16.3Central venous catheter-related bloodstream infectionsCleaning site (povidone-iodine to chlorhexidine)4
16.4Central venous catheter-related bloodstream infectionsUse of heparin4
16.4Central venous catheter-related bloodstream infectionsTunneling short-term central venous catheters4
29Hospital-acquired complications (eg, falls, delirium, functional decline, mortality)Geriatric consultation services4
46Adverse events related to fatigue in health care workersLimiting individual provider's hours of service4
26.4Falls and fall-related injuryiesUse of special flooring material in patient care areas5
43.2Performance of invasive diagnostic or therapeutic procedure on wrong body part"Sign your site" protocols5
42.1Adverse events related to discontinuities in careInformation transfer between inpatient and outpatient pharmacy2
48Missed, incomplete or not fully comprehended informed consentAsking that patients recall and restate what they have been told during informed consent1
8Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)Use of computer monitoring for potential ADEs2
24Critical events in anesthesiaIntraoperative monitoring of vital signs and oxygenation4
42.3Adverse events related to information loss at dischargeUse of structured discharge summaries5

From: 58, Practices Rated by Research Priority

Cover of Making Health Care Safer
Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Evidence Reports/Technology Assessments, No. 43.
Shojania KG, Duncan BW, McDonald KM, et al., editors.

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