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Addendum to Summary: Patient Safety Practices Rated by Strength of Evidence


After rating practices in terms of their potential impact, and on the strength of the evidence, the Editorial Board grouped them into 5 categories (Tables A-1 through A-5, adapted from Tables 57.1-57.5 of Making Health Care Safer: A Critical Analysis of Patient Safety Practices). These categorizations reflect the current state of the evidence.

If a practice that addresses a very common or severe patient safety problem receives a low rating on the impact/evidence scale, it may be because the strength of the evidence base is still weak because there have been few evaluations. As a result the practice is likely to show up at a high level on the research priority scale. However, if the practice has been studied rigorously, and there is clear evidence that its effectiveness is negligible, it is rated at the low ends of both the "strength of the evidence" (on impact/effectiveness) scale and the "research priority" scale.

For each practice listed in the Tables, a designation for the cost and complexity of implementation of the practice is included. The ratings for implementation are "Low," which corresponds to low cost and low complexity of implementation (e.g., political or technical issues); "Medium," which represents low to medium cost and high complexity, or medium to high cost and low complexity; and "High," which reflects medium to high cost and high complexity of implementation.

Several practices are not included in the tables because they were not rated. Among these are a set of practices that have long histories of use outside of medicine, but have not yet received adequate evaluation of their potential health care applications:

  • Promoting a Culture of Safety (Chapter 40).
  • Use of Human Factors Principles in Evaluation of Medical Devices (Subchapter 41.1).
  • Refining Performance of Medical Device Alarms (e.g., balancing sensitivity and specificity of alarms, ergonomic design) (Subchapter 41.2).
  • Fixed Shifts or Forward Shift Rotations of health care personnel (Chapter 46).
  • Napping Strategies for health care personnel (Chapter 46).
  • Incident Reporting (Chapter 4).

Table A-1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness *

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Item Patient Safety Problem Patient Safety Practice Implementation Cost/Complexity
1 Venous thromboembolism (VTE) Appropriate VTE prophylaxis (Ch. 31)* Low
2 Perioperative cardiac events in patients undergoing noncardiac surgery Use of perioperative beta-blockers (Ch.25) Low
3 Central venous catheter-related bloodstream infections Use of maximum sterile barriers during catheter insertion (Ch. 16.1) Low
4 Surgical site infections Appropriate use of antibiotic prophylaxis (Ch. 20.1) Low
5 Missed, incomplete or not fully comprehended informed consent Asking that patients recall and restate what they have been told during informed consent (Ch. 48) Low
6 Ventilator-associated pneumonia Continuous aspiration of subglottic secretions (CASS) (Ch. 17.2) Medium
7 Pressure ulcers Use of pressure relieving bedding materials (Ch. 27) Medium
8 Morbidity due to central venous catheter insertion Use of real-time ultrasound guidance during central line insertion (Ch. 21) High
9 Adverse events related to chronic anticoagulation with warfarin Patient self management using home monitoring devices (Ch. 9) High
10 Morbidity and mortality in post-surgical and critically ill patients Various nutritional strategies (Ch. 33) Medium
11 Central venous catheter-related bloodstream infections Antibiotic-impregnated catheters (Ch. 16.2) Low

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

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Table A-2. Patient Safety Practices with High Strength of Evidence Regarding their Impact and Effectiveness*

Item Patient Safety Problem Patient Safety Practice Implementation Cost/Complexity
12 Mortality associated with surgical procedures Localizing specific surgeries and procedures to high volume centers (Ch. 18) High (varies)
13 Ventilator-associated pneumonia Semi-recumbent positioning (Ch. 17.1) Low
14 Falls and fall injuries Use of hip protectors (Ch. 26.5) Low
15 Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection) Use of computer monitoring for potential ADEs (Ch. 8) Medium
16 Surgical site infections Use of supplemental perioperative oxygen (Ch. 20.3) Low
17 Morbidity and mortality Changes in nursing staffing (Ch. 39) Medium
18 Missed or incomplete or not fully comprehended informed consent Use of video or audio stimuli (Ch. 48) Low
19 Ventilator-associated pneumonia Selective decontamination of digestive tract (Ch. 17.3) Low
20 Morbidity and mortality in ICU patients Change in ICU structure—active management by intensivist (Ch. 38) High
21 Adverse events related to discontinuities in care Information transfer between inpatient and outpatient pharmacy (Ch. 42.1) Medium
22 Hospital-acquired urinary tract infection Use of silver alloy-coated catheters (Ch. 15.1) Low
23 Hospital-related delirium Multi-component delirium prevention program (Ch. 28) Medium
24 Hospital-acquired complications (functional decline, mortality) Geriatric evaluation and management unit (Ch. 30) High
25 Inadequate postoperative pain management Non-pharmacologic interventions (e.g., relaxation, distraction) (Ch. 37.4) Low

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

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

Item Patient Safety Problem Patient Safety Practice Implementation Cost/Complexity
26 Medication errors and adverse drug events (ADEs) primarily related to ordering process Computerized physician order entry (CPOE) and clinical decision support (CDSS) (Ch. 6) High
27 Failures to communicate significant abnormal results (e.g., pap smears) Protocols for notification of test results to patients (Ch. 42.4) Low
28 Adverse events due to transportation of critically ill patients between health care facilities Specialized teams for interhospital transport (Ch. 47) Medium
29 Medication errors and adverse drug events (ADEs) related to ordering and monitoring Clinical pharmacist consultation services (Ch. 7) Medium
30 Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile) Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) (Ch. 13) Medium
31 Surgical site infections Perioperative glucose control (Ch. 20.4) Medium
32 Stress-related gastrointestinal bleeding H2 antagonists (Ch. 34) Low
33 Pneumococcal pneumonia Methods to increase pneumococcal vaccination rate (Ch. 36) Low
34 Inadequate pain relief Acute pain service (Ch. 37.2) Medium
35 Adverse events related to anticoagulation Anticoagulation services and clinics for coumadin (Ch. 9) Medium
36 Hospital-acquired infections due to antibiotic-resistant organisms Limitations placed on antibiotic use (Ch. 14) Low
37 Hospital-acquired urinary tract infection Use of suprapubic catheters (Ch. 15.2) High
38 Contrast-induced renal failure Hydration protocols with acetylcysteine (Ch. 32) Low
39 Clinically significant misread radiographs and CT scans by non-radiologists Education interventions and continuous quality improvement strategies (Ch. 35) Low
40 Missed or incomplete or not fully comprehended informed consent Provision of written informed consent information (Ch. 48) Low
41 Failure to honor patient preferences for end-of-life care Computer-generated reminders to discuss advanced directives (Ch. 49) Medium (Varies)
42 Adverse events related to anticoagulation Protocols for high-risk drugs: nomograms for heparin (Ch. 9) Low
43 Ventilator-associated pneumonia Continuous oscillation (Ch. 17.1) Medium
44 Surgical site infections Maintenance of perioperative normothermia (Ch. 20.2) Low
45 Restraint-related injury; Falls Interventions to reduce the use of physical restraints safely (Ch. 26,2) Medium
46 Falls Use of bed alarms (Ch. 26.3) Medium
47 Contrast-induced renal failure Use of low osmolar contrast media (Ch. 32) Medium

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

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

Item Patient Safety Problem Patient Safety Practice Implementation Cost/Complexity
48 Central venous catheter-related bloodstream infections Cleaning site (povidone-iodine to chlorhexidine) (Ch. 16.3) Low
49 Central venous catheter-related bloodstream infections Use of heparin (Ch. 16.4) Low
50 Central venous catheter-related bloodstream infections Tunneling short-term central venous catheters (Ch. 16.4) Medium
51 Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality) Geriatric consultation services (Ch. 29) High
52 Inadequate pain relief in patients with abdominal pain in hospital patients Use of analgesics in the patient with acute abdomen without compromising diagnostic accuracy (Ch. 37.1) Low
53 Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations Simulator-based training (Ch. 45) Medium
54 Adverse drug events (ADEs) in drug dispensing and/or administration Use of automated medication dispensing devices (Ch. 11) Medium
55 Hospital-acquired infections Improve handwashing compliance (via education/behavior change; sink technology and placement; washing substance) (Ch. 12) Low
56 Failure to honor patient preferences for end-of-life care Use of physician order form for life-sustaining treatment (POLST) (Ch. 49) Low
57 Adverse events due to patient misidentification Use of bar coding (Ch. 43.1) Medium (Varies)
58 Adverse drug events (ADEs) in dispensing medications Unit-dosing distribution system (Ch. 10) Low
59 Critical events in anesthesia Intraoperative monitoring of vital signs and oxygenation (Ch. 24) Low
60 Adverse events during cross-coverage Standardized, structured sign-outs for physicians (Ch. 42.2) Low
61 Adverse events related to team performance issues Applications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) (Ch. 44) High
62 Adverse events related to fatigue in health care workers Limiting individual provider's hours of service (Ch. 46) High

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

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

Item Patient Safety Problem Patient Safety Practice Implementation Cost/Complexity
63 Complications due to anesthesia equipment failures Use of pre-anesthesia checklists (Ch. 23) Low
64 Adverse events related to information loss at discharge Use of structured discharge summaries (Ch. 42.3) Low
65 Surgical items left inside patients Counting sharps, instruments and sponges (Ch. 22) Low
66 Ventilator-associated pneumonia Use of sucralfate (Ch. 26.4) Low
67 Falls and fall-related injuries Use of special flooring material in patient care areas (Ch. 26.4) Medium
68 Performance of invasive diagnostic or therapeutic procedure on wrong body part "Sign your site" protocols (Ch. 43.2) Medium
69 Falls Use of identification bracelets (Ch. 26.1) Low
70 Contrast-induced renal failure Hydration protocols with theophylline (Ch. 32) Low
71 Adverse events due to transportation of critically ill patients within a hospital Mechanical rather than manual ventilation during transport (Ch. 47) Low
72 Central venous catheter-related bloodstream infections Changing catheters routinely (Ch. 16.4) High
73 Central venous catheter-related bloodstream infections Routine antibiotic prophylaxis (Ch. 16.4) Medium

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

Select for Text Version.

AHRQ Publication No. 01-E057b
Current as of July 2001


Internet Citation:

Patient Safety Practices Rated by Strength of Evidence. Addendum to Summary. July 2001. AHRQ Publication No. 01-E057b. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety/addend.htm


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