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Chapter 59. Listing of All Practices, Categorical Ratings, and Comments

Ch. # Patient Safety Target Patient Safety Practice Impact Study Strength Effect Size Vigilance Cost Complexity
6 Medication errors and adverse drug events (ADEs) primarily related to ordering process Computerized physician order entry (CPOE) with clinical decision support system (CDSS) High Medium1 Modest Medium High2 High
7 Medication errors and ADEs related to ordering and monitoring Clinical pharmacist consultation services High Medium Modest3 Low High Low
8 ADEs related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection) Use of computer monitoring for potential ADEs Medium Medium Robust4 Low Medium5 Low
9 Adverse events related to anticoagulation Protocols for high risk drugs: nomograms for heparin Medium Medium6 Robust7 Medium Low Low
9 Adverse events related to anticoagulation Anticoagulation services and clinics for coumadin8 High Medium Unclear Low Medium Low
9 Adverse events related to chronic anticoagulation with warfarin Patient self-management using home monitoring devices High High Robust Medium Medium9 High10
10 ADEs in dispensing medications Unit-dosing distribution system Medium11 Medium Unclear Low Low Low
11 ADEs in drug dispensing and/or administration Use of automated medication dispensing devices High Medium12 Unclear Medium Medium13 Low
12 Hospital-acquired infections Improved handwashing compliance (via education/behavior change; sink technology and placement; washing substance) High Medium14 Unclear15 Low Low Low16
13 Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile) Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) High Medium17 Robust Medium18 Medium Low19
14 Hospital-acquired infections due to antibiotic-resistant organisms Limitations placed on antibiotic use High20 Medium Modest Medium21 Low Low
15.1 Hospital-acquired urinary tract infection Use of silver alloy-coated catheters High High Unclear22 Low Low Low
15.2 Hospital-acquired urinary tract infection Use of suprapubic catheters High High Unclear23 Medium High High
16.1 Central venous catheter-related blood infections Use of maximum sterile barriers during catheter insertion Medium High Robust Low Low Low24
16.2 Central venous catheter-related blood infections Antibiotic-impregnated catheters Medium High Robust Low25 Low Low
16.3 Central venous catheter-related blood infections Cleaning site (povidone-iodine to chlorhexidine) Medium High Unclear Low Low Low
16.4 Central venous catheter-related blood infections Changing catheters routinely Medium High Negligible± NA High High
16.4 Central venous catheter-related blood infections Use of heparin Medium High Unclear Medium Low Low
16.4 Central venous catheter-related blood infections Tunneling short-term central venous catheters Medium High Unclear Low Low High
16.4 Central venous catheter-related blood infections Routine antibiotic prophylaxis Medium Medium Negligible Medium Medium Low
17.1 Ventilator-associated pneumonia Semi-recumbent positioning High Medium Robust26 Low Low Low
17.1 Ventilator-associated pneumonia Continuous oscillation High High Robust27 Medium Medium Low
17.2 Ventilator-associated pneumonia Continuous aspiration of subglottic secretions (CASS) High High Robust28 Low Low High29
17.3 Ventilator-associated pneumonia Selective decontamination of digestive tract High High Robust30 Medium31 Low Low
17.4 Ventilator-associated pneumonia Sucralfate High High Unclear High32 Low Low
18 Mortality associated with surgical procedures Localizing specific surgeries and procedures to high volume centers High Medium33 Varies Medium Varies High
20.1 Surgical site infections Appropriate use of antibiotic prophylaxis Medium34 High Robust Medium35 Low Low
20.2 Surgical site infections Maintenance of perioperative normothermia High Medium36 Robust Medium37 Low Low
20.3 Surgical site infections Use of supplemental perioperative oxygen High Medium38 Robust Low Low Low
20.4 Surgical site infections Perioperative glucose control High Medium Robust Medium Low High39
21 Morbidity due to central venous catheter insertion Use of real-time ultrasound guidance during central line insertion High High Robust40 Low41 Medium High
22 Surgical items left inside patient Counting sharps, instruments, sponges Insuff. Info.42 Low Not rated Not rated Low Low
23 Complications due to anesthesia equipment failures Use of preoperative anesthesia checklists Low43 Low Not rated Not rated Low Low
24 Critical events in anesthesia Intraoperative monitoring of vital signs and oxygenation Low44 Medium45 Unclear46 Low Low Low
25 Perioperative cardiac events in patients undergoing noncardiac surgery Use of perioperative beta-blockers High High Robust Medium Low Low
26.1 Falls Use of identification bracelets Medium Medium Negligible Low Low Low
26.2 Restraint-related injuries; Falls Interventions to reduce the use of physical restraints safely Medium Medium Unclear47 Medium Medium Low
26.3 Falls Use of bed alarms Medium Medium Unclear Low48 Medium49 Low
26.4 Falls and fall-related injuries Use of special flooring material in patient care areas Medium Low Not rated Not rated High Low
26.5 Falls and fall injuries Use of hip protectors Medium High Robust Medium Low50 Low51
27 Pressure ulcers Use of pressure relieving bedding materials High High Robust52 Low High Low
28 Hospital-related delirium Multi-component delirium prevention program High Medium Robust Low Medium Low
29 Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality) Geriatric consultation services High High Varies53 Low Medium High

± Actually, studies show a detrimental effect of practice.

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