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Table A-3. Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness*


Item:26
Patient Safety Problem: Medication errors and adverse drug events (ADEs) primarily related to ordering process
Patient Safety Practice: Computerized physician order entry (CPOE) and clinical decision support (CDSS)(Ch. 6)
Implementation Cost/Complexity: High

Item:27
Patient Safety Problem: Failures to communicate significant abnormal results (e.g., pap smears)
Patient Safety Practice: Protocols for notification of test results to patients (Ch. 42.4)
Implementation Cost/Complexity: Low

Item:28
Patient Safety Problem: Adverse events due to transportation of critically ill patients between health care facilities
Patient Safety Practice: Specialized teams for interhospital transport (Ch. 47)
Implementation Cost/Complexity: Medium

Item:29
Patient Safety Problem: Medication errors and adverse drug events (ADEs) related to ordering and monitoring
Patient Safety Practice: Clinical pharmacist consultation services (Ch. 7)
Implementation Cost/Complexity: Medium

Item:30
Patient Safety Problem: Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)
Patient Safety Practice: Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel)(Ch. 13)
Implementation Cost/Complexity: Medium

Item:31
Patient Safety Problem: Surgical site infections
Patient Safety Practice: Perioperative glucose control (Ch. 20.4)
Implementation Cost/Complexity: Medium

Item:32
Patient Safety Problem: Stress-related gastrointestinal bleeding
Patient Safety Practice: H2 antagonists (Ch. 34)
Implementation Cost/Complexity: Low

Item:33
Patient Safety Problem: Pneumococcal pneumonia
Patient Safety Practice: Methods to increase pneumococcal vaccination rate (Ch. 36)
Implementation Cost/Complexity: Low

Item:34
Patient Safety Problem: Inadequate pain relief
Patient Safety Practice: Acute pain service (Ch. 37.2)
Implementation Cost/Complexity: Medium

Item:35
Patient Safety Problem: Adverse events related to anticoagulation
Patient Safety Practice: Anticoagulation services and clinics for coumadin (Ch. 9)
Implementation Cost/Complexity: Medium

Item:36
Patient Safety Problem: Hospital-acquired infections due to antibiotic-resistant organisms
Patient Safety Practice: Limitations placed on antibiotic use (Ch. 14)
Implementation Cost/Complexity: Low

Item:37
Patient Safety Problem: Hospital-acquired urinary tract infection
Patient Safety Practice: Use of suprapubic catheters (Ch. 15.2)
Implementation Cost/Complexity: High

Item:38
Patient Safety Problem: Contrast-induced renal failure
Patient Safety Practice: Hydration protocols with acetylcysteine (Ch. 32)
Implementation Cost/Complexity: Low

Item:39
Patient Safety Problem: Clinically significant misread radiographs and CT scans by non-radiologists
Patient Safety Practice: Education interventions and continuous quality improvement strategies (Ch. 35)
Implementation Cost/Complexity: Low

Item:40
Patient Safety Problem: Missed or incomplete or not fully comprehended informed consent
Patient Safety Practice: Provision of written informed consent information (Ch. 48)
Implementation Cost/Complexity: Low

Item:41
Patient Safety Problem: Failure to honor patient preferences for end-of-life care
Patient Safety Practice: Computer-generated reminders to discuss advanced directives (Ch. 49)
Implementation Cost/Complexity: Medium (varies)

Item:42
Patient Safety Problem: Adverse events related to anticoagulation
Patient Safety Practice: Protocols for high-risk drugs: nomograms for heparin (Ch. 9)
Implementation Cost/Complexity: Low

Item:43
Patient Safety Problem: Ventilator-associated pneumonia
Patient Safety Practice: Continuous oscillation (Ch. 17.1)
Implementation Cost/Complexity: Medium

Item:44
Patient Safety Problem: Surgical site infections
Patient Safety Practice: Maintenance of perioperative normothermia (Ch. 20.2)
Implementation Cost/Complexity: Low

Item:45
Patient Safety Problem: Restraint-related injury; Falls
Patient Safety Practice: Interventions to reduce the use of physical restraints safely (Ch. 26.2)
Implementation Cost/Complexity: Medium

Item:46
Patient Safety Problem: Falls
Patient Safety Practice: Use of bed alarms (Ch. 26.3)
Implementation Cost/Complexity: Medium

Item:47
Patient Safety Problem: Contrast-induced renal failure
Patient Safety Practice: Use of low osmolar contrast media (Ch. 32)
Implementation Cost/Complexity: Medium


Abbreviations: Ch. = Chapter
*Items within a particular category are not necessarily in rank order. Items are for reference only.

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