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Table A-4. Patient Safety Practices with Lower Impact and/or Strength of Evidence*


Item:48
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Cleaning site (povidone-iodine to chlorhexidine)(Ch. 16.3)
Implementation Cost/Complexity: Low

Item:49
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Use of heparin (Ch. 16.4)
Implementation Cost/Complexity: Low

Item:50
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Tunneling short-term central venous catheters (Ch. 16.4)
Implementation Cost/Complexity: Medium

Item:51
Patient Safety Problem: Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)
Patient Safety Practice: Geriatric consultation services (Ch. 29)
Implementation Cost/Complexity: High

Item:52
Patient Safety Problem: Inadequate pain relief in patients with abdominal pain in hospital patients
Patient Safety Practice: Use of analgesics in the patient with acute abdomen without compromising diagnostic accuracy (Ch. 37.1)
Implementation Cost/Complexity: Medium

Item:53
Patient Safety Problem: Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations
Patient Safety Practice: Simulator-based training (Ch. 45)
Implementation Cost/Complexity: Medium

Item:54
Patient Safety Problem: Adverse drug events (ADEs) in drug dispensing and/or administration
Patient Safety Practice: Use of automated medication dispensing devices (Ch. 11)
Implementation Cost/Complexity: Medium

Item:55
Patient Safety Problem: Hospital-acquired infections
Patient Safety Practice: Improve handwashing compliance (via education/behavior change; sink technology and placement; washing substance) (Ch. 12)
Implementation Cost/Complexity: Low

Item:56
Patient Safety Problem: Failure to honor patient preferences for end-of-life care
Patient Safety Practice: Use of physician order form for life-sustaining treatment (POLST) (Ch. 49)
Implementation Cost/Complexity: Low

Item:57
Patient Safety Problem: Adverse events due to patient misidentification
Patient Safety Practice: Use of bar coding (Ch. 43.1)
Implementation Cost/Complexity: Medium (varies)

Item:58
Patient Safety Problem: Adverse drug events (ADEs) in dispensing medications
Patient Safety Practice: Unit-dosing distribution system (Ch. 10)
Implementation Cost/Complexity: Low

Item:59
Patient Safety Problem: Critical events in anesthesia
Patient Safety Practice: Intraoperative monitoring of vital signs and oxygenation (Ch. 24)
Implementation Cost/Complexity: Low

Item:60
Patient Safety Problem: Adverse events during cross-coverage
Patient Safety Practice: Standardized, structured sign-outs for physicians (Ch. 42.2)
Implementation Cost/Complexity: Low

Item:61
Patient Safety Problem: Adverse events related to team performance issues
Patient Safety Practice: Applications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) (Ch. 44)
Implementation Cost/Complexity: High

Item:62
Patient Safety Problem: Adverse events related to fatigue in health care workers
Patient Safety Practice: Limiting individual provider's hours of service (Ch. 46)
Implementation Cost/Complexity: High


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

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