Structured Abstract

Contents

• Acknowledgements
• ES. Executive Summary
  • ES.1. Background/Introduction
  • ES.2. Objectives
  • ES.3. Methods
  • ES.4. Results
  • ES.5. Discussion
  • ES.6. Limitations
  • ES.7. Conclusions
  • ES.8. Future Research Needs
  • References
• Introduction
  • References
• Methods
  • Step 1. Development of Conceptual Framework
  • Step 2. Identification, Selection, and Prioritization of Harm Area Topics
  • Step 3. Identification, Selection, and Prioritization of Patient Safety Practices
  • Step 4. Literature Searches
  • Step 5. Review of the Evidence
  • Step 6. Report Development
  • References
• 1. Diagnostic Errors
  • Introduction
  • 1.1. Patient Safety Practice: Clinical Decision Support
    Kendall K. Hall, Kristen Miller, Eleanor Fitall, and Katharine Witgert.
  • 1.2. Patient Safety Practice: Result Notification Systems
    Kendall K. Hall, Gordon Schiff, and Andrea Hassol.
  • 1.3. Patient Safety Practice: Education and Training
    Kendall K. Hall, Gordon Schiff, and Katharine Witgert.
  • 1.4. Patient Safety Practice: Peer Review
    Kendall K. Hall, Gordon Schiff, and Katharine Witgert.
  • Conclusion and Comment
• 2. Failure To Rescue
  Kendall K. Hall, Andrea Lim, and Bryan Gale.
  • Introduction
  • 2.1. PSP 1: Patient Monitoring Systems
    Editors: Bruce Spurlock, Kristen Miller, and Katharine Witgert.
  • 2.2. PSP 2: Rapid Response Teams
    Editors: Miller Kristen and Katharine Witgert.
  • Conclusion and Comment
• 3. Sepsis Recognition
  Bryan Gale and Kendall K. Hall.
  • Introduction
  • 3.1. Patient Safety Practice 1: Sepsis Screening Tools
  • 3.2. Patient Safety Practice 2: Sepsis Patient Monitoring Systems
  • 3.3. Multicomponent Sepsis Interventions
  • Conclusion and Comment
• 4. Clostridioides difficile Infection
  Elizabeth Schoyer, Kendall K. Hall, and Eleanor Fitall.
  • Introduction
  • 4.1. PSP 1: Antimicrobial Stewardship
    Arjun Srinivasan.
  • 4.2. PSP 2: Hand Hygiene
    Editors: Arjun Srinivasan and Andrea Hasssol.
  • 4.3. CDI PSP 3: Environmental Cleaning and Decontamination
    Editors: Arjun Srinivasan and Katharine Witgert.
  • 4.4. PSP 4: Surveillance
    Editors: Arjun Srinivasan and Luba Katz.
  • 4.5. PSP 5: Testing
    Andrea Hassol.
  • 4.6. Multicomponent CDI Prevention Interventions
    Katharine Witgert.
  • Conclusion
• 5. Infections Due to Other Multidrug-Resistant Organisms
  Elizabeth Gall, Anna Long, and Kendall K. Hall.
  • Introduction
  • 5.1. PSP: Chlorhexidine Bathing To Control MDROs
    Sam Watson.
  • 5.2. PSP: Hand Hygiene To Reduce MDRO Transmission
    Editors: Andrea Hassol and Sam Watson.
  • 5.3. PSP: Active Surveillance for MDROs
    Editors: Luba Katz and Sam Watson.
  • 5.4. PSP: Environmental Cleaning and Disinfection
    Sam Watson.
  • 5.5. PSP: Minimizing Exposure to Invasive Devices and Reducing Device-Associated Risks
    Editors: Katharine Witgert and Sam Watson.
  • 5.6. PSP: Communication of Patients’ MDRO Status
    Editors: Katharine Witgert and Sam Watson.
  • Conclusion and Comment
• 6. Carbapenem-Resistant Enterobacteriaceae
  Elizabeth Gall and Anna Long.
  • Introduction
  • 6.1. PSP: Contact Precautions To Prevent CRE Infections
  • Conclusion
• 7. Harms Due to Anticoagulants
  Sarah J. Shoemaker-Hunt and Brandy Wyant.
  • Introduction
  • 7.1. Patient Safety Practice 1: Anticoagulation Management Service in the Ambulatory Setting
    Scott Winiecki.
  • 7.2. Patient Safety Practice 2: Use of Dosing Protocols or Nomograms for Newer Oral Anticoagulants
    Editors: Katharin Witgert and Scott Winiecki.
  • 7.3. Patient Safety Practice 3: Interventions To Support Safe Transitions and Continuation of Patients’ Anticoagulants Post Discharge
    Scott Winiecki.
  • Conclusion
• 8. Harms Due to Diabetic Agents
  Lisa LeRoy and Sonja Richard.
  • Introduction
  • 8.1. PSP1: Use of Standardized Insulin Protocols To Reduce Risk of Serious Hypoglycemia in Hospitals Due to Administration Errors
  • 8.2. PSP2: Use of Teach-Back in Diabetes Medication Management
  • Conclusion and Comment
• 9. Reducing Adverse Drug Events in Older Adults
  Tara R. Earl, Nicole D. Katapodis, and Stephanie R. Schneiderman.
  • Introduction
  • 9.1. Reducing ADEs in Older Adults
  • 9.2. Patient Safety Practice: Deprescribing To Reduce Polypharmacy in Older Adults
  • 9.3. Patient Safety Practice: Using the STOPP Criteria To Reduce the Use of PIMs in Older Adults
  • 9.4. Implementation
  • Conclusion and Comment
• 10. Harms Due to Opioids
  Sarah J. Shoemaker-Hunt, Cori Sheedy, and Brandy Wyant.
  • Introduction
  • 10.1. Patient Safety Practice 1: Opioid Stewardship
  • 10.2. Patient Safety Practice 2: Initiation of Medication-Assisted Treatment in Healthcare Settings
  • Conclusion and Comment
• 11. Patient Identification Errors in the Operating Room
  Cori Sheedy and Sonja Richard.
  • Introduction
  • 11.1. Practice Description
  • Gaps and Future Directions
• 12. Infusion Pumps
  Lynn Hoffman and Olivia Bacon.
  • Introduction
  • 12.1. PSP 1: Structured Process Change and Workflow Redesign
  • 12.2. PSP 2: Staff Education and Training
  • Conclusion and Comment
• 13. Alarm Fatigue
  Meghan Woo and Olivia Bacon.
  • Introduction
  • 13.1. Patient Safety Practice 1: Safety Culture
  • 13.2. Patient Safety Practice 2: Risk Assessment
  • Conclusion and Comment
• 14. Delirium
  Lynn Hoffman, Aline Holmes, Jennifer Riggs, and Stephanie Schneiderman.
  • Introduction
  • 14.1. PSP 1: Delirium Screening and Assessment
  • 14.2. PSP 2: Staff Education and Training
  • 14.3. PSP3: Nonpharmacological Interventions To Prevent Intensive Care Unit Delirium
  • Conclusion and Comment
• 15. Care Transitions
  Tara Earl, Nicole Katapodis, and Stephanie Schneiderman.
  • Introduction
  • 15.1. BOOST: Better Outcomes by Optimizing Safe Transitions
  • 15.2. CTI: Care Transitions Intervention
  • 15.3. TCM: Transitional Care Model
  • 15.4. General Issues
  • Conclusion and Comment
• 16. Venous Thromboembolism
  Eleanor Fitall and Kendall K. Hall.
  • Introduction
  • 16.1. Patient Safety Practice: Use of Aspirin for VTE Prophylaxis
  • Conclusion and Comment
• 17. Cross-Cutting Patient Safety Topics/Practices
  Dana Costar.
  • Introduction
  • 17.1. Patient and Family Engagement
    Sonja Richard and Lisa LeRoy.
  • 17.2. Safety Culture
    Dana Costar, Kendall K. Hall, and Heidi Wald.
  • 17.3. Clinical Decision Support
    Lynn Hoffman and Andreas Hassol.
  • 17.4. Cultural Competency
    Elizabeth Schoyer and Martin Hatlie.
  • 17.5. Monitoring, Auditing, and Feedback
    Lynn Hoffman, Andreas Hassol, and Stephanie Schneiderman.
  • 17.6. Teamwork and Team Training
    Dana Costar, Heidi King, and James Battles.
  • 17.7. Education and Training Through Simulation
    Dana Costar and James Battles.
• Discussion
• Limitations
• Conclusions
• Future Research Needs
• Appendix A. PRISMA Flow Diagrams
• Appendix B. Evidence Tables
• Appendix C. Search Terms

Suggested citation:

Hall KK, Shoemaker-Hunt S, Hoffman L, Richard S, Gall E, Schoyer E, Costar D, Gale B, Schiff G, Miller K, Earl T, Katapodis N, Sheedy C, Wyant B, Bacon O, Hassol A, Schneiderman S, Woo M, LeRoy L, Fitall E, Long A, Holmes A, Riggs J, Lim A. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. (Prepared by Abt Associates Inc. under Contract No. 233-2015-00013-I.) AHRQ Publication No. 20-0029-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2020.

This project was funded under contract/grant number Contract No. 233-2015-00013-I, Task Order #HHSP23337002T from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this product as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this product.

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