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Chapter 57. Practices Rated by Strength of Evidence

After rating practices on a metric for potential impact, and on the strength of the evidence, we grouped them into 5 categories (Tables 57.1-57.5). These categorizations reflect the current state of the evidence. If a practice that addresses a highly prevalent or severe patient safety target receives a low rating on the impact/evidence scale, it may be because the strength of the evidence base is still weak due to lack of 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 Tables 57.1 through 57.5, 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 (e.g., political, technical); "Medium," which signifies 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.

Several practices are not included in the tables because they were not rated. This set of practices have long histories of use outside of medicine, but have not yet received enough evaluations for their potential healthcare 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 (Chapter 46).
  • Napping Strategies (Chapter 46).

Table 57.1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness

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

Table 57.2 Patient Safety Practices with High Strength of Evidence Regarding their Impact and Effectiveness

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

Table 57.3 Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness

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

Table 57.4 Patient Safety Practices with Lower Impact and/or Strength of Evidence

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

57.5 Patient Safety Practices with Lowest Impact and/or Strength of Evidence

Chapter Patient Safety Target Patient Safety Practice Implementation Cost/Complex
23 Complications due to anesthesia equipment failures Use of pre-anesthesia checklists Low
42.3 Adverse events related to information loss at discharge Use of structured discharge summaries Low
22 Surgical items left inside patients Counting sharps, instruments and sponges Low
17.4 Ventilator-associated pneumonia Use of sucralfate Low
26.4 Falls and fall-related injuries Use of special flooring material in patient care areas Medium
43.2 Performance of invasive diagnostic or therapeutic procedure on wrong body part Protocols Medium
26.1 Falls Use of identification bracelets Low
32 Contrast-induced renal failure Hydration protocols with theophylline Low
47 Adverse events due to transportation of critically ill patients within a hospital Mechanical rather than manual ventilation during transport Low
16.4 Central venous catheter-related bloodstream infections Changing catheters routinely High
16.4 Central venous catheter-related bloodstream infections Routine antibiotic prophylaxis Medium

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