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

Ch. # Patient Safety Target Patient Safety Practice Impact Study Strength Effect Size Vigilance Cost Complexity
30 Hospital-acquired complications (functional decline, mortality) Geriatric evaluation and management unit High High Modest54 Low Medium High
31 Venous thromboembolism (VTE) Appropriate VTE prophylaxis High High Robust Medium Low Low55
32 Contrast-induced renal failure Use of low osmolar contrast media Medium High Robust Low High56 Low
32 Contrast-induced renal failure Hydration protocols with theophylline Medium High Negligible Low Low Low
32 Contrast-induced renal failure Hydration protocols with acetylcysteine Medium Medium57 Robust Low Low Low
33 Morbidity and mortality in post-surgical and critically ill patients Various nutritional strategies High High Robust58 Medium Medium Low
34 Stress-related gastrointestinal bleeding H2-antagonists Medium High Unclear Medium59 Low Low
35 Clinically significant misread radiographs and CT scans by non-radiologists Education interventions and continuous quality improvement strategies Medium Medium Robust Low Low Low
36 Pneumococcal pneumonia Methods to increase pneumococcal vaccination rate Medium High Unclear60 Low 61 Low Low
37.1 Inadequate pain relief in hospital patients with abdominal pain Use of analgesics in patients with acute abdomen without compromising diagnostic accuracy High Medium62 Robust Medium Low Low63
37.2 Inadequate pain relief Acute pain service High Medium Robust64 Low65 Medium Low
37.4 Inadequate postoperative pain management Non-pharmacologic interventions (e.g., relaxation, distraction) High High Unclear Low Low Low
38 Morbidity and mortality in ICU patients Change in ICU structure—active management by intensivist High Medium Robust66 Low Medium High
39 Morbidity and mortality Changes in nursing staffing High Medium67 Varies Low High Low68
40 Any safety problem amenable to culture Promoting a culture of safety Insuff. Info. **69     Varies High
41.1 Medical device related adverse events Use of human factors principles in evaluation of medical devices Insuff. Info. **70     Varies High
41.2 Adverse events Refining performance of medical device alarms (e.g., balancing sensitivity and specificity of alarms, ergonomic design) High71 **72     Varies High
42.1 Adverse events related to discontinuities in care Information transfer between inpatient and outpatient pharmacy High Medium Robust Low Medium73 Low
42.2 Adverse events during cross-coverage Standardized, structured sign-outs for physicians Medium Low Not rated Not rated Low74 Low
42.3 Adverse events related to information loss at discharge Use of structured discharge summaries Insuff. Info Low75 Not rated Not rated Low Low
42.4 Failures to communicate significant abnormal results (e.g., pap smears) Protocols for notification of test results to patients Medium Medium Modest Low Low Low
43.1 Adverse events due to patient misidentification Use of bar coding High76 Low Not rated Not rated Varies77 High
43.2 Performance of invasive diagnostic or therapeutic procedure on wrong body part "Sign your site" protocols High Low Not rated Not rated Low High
44 Adverse events related to team performance issues Application of aviation style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) High78 Low Not rated Not rated Medium High
45 Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations Simulator-based training Insuff. Info79 Medium80 Unclear81 Low Medium Low
46 Adverse events related to fatigue in healthcare workers Limiting individual provider's hours of service Insuff. Info. Medium Unclear Low High High
46 Adverse events related to fatigue in healthcare workers Fixed shifts or forward shift rotations Insuff. Info. **82     Varies83 Varies73
46 Adverse events related to fatigue in healthcare workers Napping strategies Insuff. Info. **84     High85 Low
47 Adverse events due to transportation of critically ill patients between healthcare facilities Specialized teams for interhospital transport Medium Medium86 Modest Low Medium Low
47 Adverse events due to transportation of critically ill patients within a hospital Mechanical ventilation Medium Medium Negligible Low Low Low
48 Missed, incomplete or not fully comprehended informed consent Asking that patients recall and restate what they have been told during informed consent High Medium Robust Low Low Low87
48 Missed, incomplete or not fully comprehended informed consent Use of video or audio stimuli High Medium Modest Low Low88 Low
48 Missed, incomplete or not fully comprehended informed consent Provision of written informed consent information High Medium Unclear Low Low Low
49 Failure to honor patient preferences for end-of-life care Computer-generated reminders to discuss advanced directives High Medium Robust Low Medium89 Low
49 Failure to honor patient preferences for end-of-life care Use of physician order form for life-sustaining treatment (POLST) High Low Not rated Not rated Low Low90

± Actually, studies show a detrimental effect of practice.

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