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Table A-5. Patient Safety Practices with Lowest Impact and/or Strength of Evidence*


Item:63
Patient Safety Problem: Complications due to anesthesia equipment failures
Patient Safety Practice: Use of pre-anesthesia checklists (Ch. 23)
Implementation Cost/Complexity: Low

Item:64
Patient Safety Problem: Adverse events related to information loss at discharge
Patient Safety Practice: Use of structured discharge summaries (Ch. 42.3)
Implementation Cost/Complexity: Low

Item:65
Patient Safety Problem: Surgical items left inside patients
Patient Safety Practice: Counting sharps, instruments and sponges (Ch. 22)
Implementation Cost/Complexity: Low

Item:66
Patient Safety Problem: Ventilator-associated pneumonia
Patient Safety Practice: Use of sucralfate (Ch. 26.4)
Implementation Cost/Complexity: Low

Item:67
Patient Safety Problem: Falls and fall-related injuries
Patient Safety Practice: Use of special flooring material in patient care areas (Ch. 26.4)
Implementation Cost/Complexity: Medium

Item:68
Patient Safety Problem: Performance of invasive diagnostic or therapeutic procedure on wrong body part
Patient Safety Practice: "Sign your site" protocols (Ch. 43.2)
Implementation Cost/Complexity: Medium

Item:69
Patient Safety Problem: Falls
Patient Safety Practice: Use of identification bracelets (Ch. 26.1)
Implementation Cost/Complexity: Low

Item:70
Patient Safety Problem: Contrast-induced renal failure
Patient Safety Practice: Hydration protocols with theophylline (Ch. 32)
Implementation Cost/Complexity: Low

Item:71
Patient Safety Problem: Adverse events due to transportation of critically ill patients within a hospital
Patient Safety Practice: Mechanical rather than manual ventilation during transport (Ch. 47)
Implementation Cost/Complexity: Low

Item:72
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Changing catheters routinely (Ch. 16.4)
Implementation Cost/Complexity: High

Item:73
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Routine antibiotic prophylaxis (Ch. 16.4)
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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