Table 1, Chapter 44Summary table*

Patient Safety PracticeScope of the Problem Targeted by the PSP(Frequency/Severity)Strength of Evidence for Effectiveness of the PSPsEvidence or Potential for Harmful Unintended ConsequencesEstimate of CostImplementation Issues: How Much do We Know?/How Hard Is it?
Practices Designed for a Specific Patient Safety Target
Adverse Drug Events
High-alert drugs: patient safety practices for intravenous anticoagulants;in-depth reviewCommon/ModerateLowLow-to-moderateLowLittle/Moderate
Use of clinical pharmacists to prevent adverse drug events;brief reviewCommon/LowModerate-to-highLowHighLittle/Moderate
The Joint Commission's “Do Not Use” list; brief reviewCommon/LowLowNegligibleLowLittle/Probably not difficult
Smart infusion pumps; brief reviewCommon/LowLowLowModerateModerate/Moderate
Infection Control
Barrier precautions, patient isolation, and routine surveillance for the prevention of healthcare-associated infections; brief reviewCommon/ModerateModerateModerate (isolation of patients)Moderate-to-highModerate/Moderate
Interventions to improve hand hygiene compliance; brief reviewCommon/ModerateLowLowLowModerate/Moderate
Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infections; brief reviewCommon/ModerateModerate-to-highLowLowModerate/Moderate
Prevention of central line-associated bloodstream infections; brief reviewCommon/ModerateModerate-to-highLowLow-to-moderateModerate-to-difficult/Not difficult (implementation of a “bundle”)-to-moderate (understanding organization culture and context)
Ventilator-associated pneumonia; brief reviewCommon/HighModerate-to-highLowLow-to-moderateModerate/Moderate
Interventions to allow the reuse of single use devices; brief reviewCommon/LowLowLowLowA lot/Not difficult
Surgery, Anesthesia, and Perioperative Medicine
Preoperative checklists and anesthesia checklists to prevent a number of operative safety events, such as surgical site infections and wrong site surgeries; in-depth reviewCommon/ModerateHighNegligibleLowA lot/Moderate
The use of ACS-NSQIP report cards and outcome measurements to decrease perioperative morbidity and mortality; in-depth reviewCommon/HighModerate-to-highLowModerateModerate/Moderate
New interventions to prevent surgical items from being left inside a patient; brief reviewRare/LowLowNegligibleLow if it simply involves more frequent manual counting; high if RFID is usedLittle
Operating room integration and display systems, such as a centralized display of consolidated data; brief reviewCommon/Low-to-highLowNegligibleModerateModerate/Moderate
Use of beta blockers to prevent perioperative cardiac events; brief reviewCommon/HighHigh evidence harms may equal or exceed benefitsHigh (death, stroke, hypotension, and bradycardia)LowNA
Use of real-time ultrasound guidance during central line insertion to increase the proportion correctly placed on the first attempt; brief reviewCommon/Low-to-moderateHighNegligibleLow-to-moderateA lot/Moderate
Safety Practices for Hospitalized Elders
Multicomponent interventions to prevent in-facility falls; in-depth reviewCommon/LowHighModerate (increased use of restraints and/or sedation)ModerateModerate/Moderate
Multicomponent interventions to prevent in-facility delirium; in-depth reviewCommon/LowModerateLowModerateModerate/Moderate
General Clinical Topics
Multicomponent initiatives to prevent pressure ulcers; in-depth reviewCommon/ModerateModerateNegligibleModerateModerate/Moderate
Inpatient, intensive, glucose control strategies to reduce death and infection; in-depth reviewCommon/ModerateModerate-to-high evidence it doesn't helpHigh (hypoglycemia)Low-to-moderateNA
Interventions to prevent contrast-induced acute kidney injury; in-depth reviewCommon/LowLowNegligibleLowLittle/Not difficult
Rapid-response systems to prevent failure-to-rescue; in-depth reviewCommon/HighModerateLowModerateModerate/Moderate
Medication reconciliation supported by clinical pharmacists; in-depth reviewCommon/LowModerateLowModerateModerate/Moderate
Identifying patients at risk for suicide; brief reviewRare/HighLowLowModerateLittle/Moderate
Strategies to prevent stress-related gastrointestinal bleeding (stress ulcer prophylaxis); brief reviewRare/ModerateModerateModerate (pneumonia)ModerateLittle/Not difficult
Strategies to increase appropriate prophylaxis for venous thromboembolism; brief reviewCommon/ModerateHighModerate(bleeding)LowLittle/Moderate
Preventing patient death or serious injury associated with radiation exposure from fluoroscopy and computed tomography through technical interventions, appropriate utilization, and use of algorithms and protocols; brief reviewRare/HighModerateNegligibleLowModerate/Not difficult
Ensuring documentation of patient preferences for life-sustaining treatment, such as advanced directives; brief reviewCommon/ModerateModerateLowLowModerate/Moderate
Increasing nurse-to-patient staffing ratios to prevent death; in-depth reviewCommon/HighModerateLowHighA lot/Not difficult
Practices Designed To Improve Overall System/Multiple Targets
Increasing nurse-to-patient staff ratios to prevent falls, pressure ulcers, and other nursing sensitive outcomes (other than mortality); in-depth reviewCommon/HighLowLowHighA lot/Not difficult
Incorporation of human factors and ergonomics in the design of health care practices by hiring an expert or training clinicians in human factors; in-depth reviewPotentially applicable to all patient safety problemsNot assessed systematically, but moderate-to-high evidence for some specific applicationsNegligibleModerateA lot/Moderate
Promoting engagement by patients and families to reduce adverse events (such as patients encouraging providers to wash their hands); in-depth reviewCommonEmerging practice (few studies available)UncertainLowLittle/Moderate
Interventions to promote a culture of safety; in-depth reviewCommon/Low-to-highLowUncertainLow–to-moderate (varies)Moderate/Not difficult-to-moderate (varies with intervention)
Patient safety practices targeted at diagnostic errors; in-depth reviewCommon/HighEmerging practice (few studies available)UncertainVariesVaries
Monitoring patient safety problems; in-depth reviewCommon/Low-to-highLowNegligibleHighModerate/Difficult
Interventions to improve care transitions at hospital discharge; in-depth reviewCommon/ModerateLowNegligibleModerate-to-highLittle/Difficult
Use of simulation-based training and exercises; in-depth reviewCommon/Moderate-to-highModerate-to-high for specific topicsUncertainModerateModerate
Obtaining informed consent from patients to improve patient understanding of potential risks of medical procedures; brief reviewCommon/ModerateModerateNegligibleLowModerate/Not difficult
Team-training in health care; brief reviewCommon/HighModerateLowModerateModerate/Moderate-to-difficult
Computerized provider order entry (CPOE) with clinical decision support systems (CDSS); brief reviewCommon/ModerateLow-to-moderateLow-to-moderateHighModerate/Difficult
Interventions to prevent tubing misconnections; brief reviewCommon/ModerateLowLowLowModerate/Not difficult
Limiting trainee work hours; brief reviewCommon/ModerateLowModerate (at least); includes lack of training timeHighModerate/Difficult

Abbreviations: ACS NSQIP=American College of Surgeons National Surgical Quality Improvement Program; NA = not available; PSP: Patient Safety Practice; RFID = radio-frequency identification.


In some cases, the text in the “PSP” column differs slightly from the chapter heading for that PSP. This difference is attributable to our Technical Expert Panel's desire to include the target safety problem (if the practice is in fact targeted at a specific safety problem), more specification, or an example of the PSP (e.g., adding “such as a centralized display of consolidated data” to the PSP designated as “operating room integration and display systems”).

Rating Scales:

  • Scope of the problem targeted by the PSP (frequency/severity): frequency = rare or common; severity = low, moderate, or high.
  • Strength of evidence for effectiveness of the PSPs: low, moderate, or high.
  • Evidence or potential for harmful unintended consequences: negligible, low, moderate, or high.
  • Estimate of cost: low, moderate, or high.
  • Implementation issues: How much do we know? = little, moderate, or a lot; How hard is it? = not difficult, moderate, or difficult.

From: Chapter 44, Discussion

Cover of Making Health Care Safer II
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Evidence Reports/Technology Assessments, No. 211.

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