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

Patient Safety Problem: Mortality associated with surgical procedures
Patient Safety Practice: Localizing specific surgeries and procedures to high volume centers (Ch.18)
Implementation Cost/Complexity: High (varies)

Patient Safety Problem: Ventilator-associated pneumonia
Patient Safety Practice: Semi-recumbent positioning (Ch. 17.1)
Implementation Cost/Complexity: Low

Patient Safety Problem: Falls and fall injuries
Patient Safety Practice: Use of hip protectors (Ch. 26.5)
Implementation Cost/Complexity: Low

Patient Safety Problem: Adverse drug events (ADEs) related to targeted classes (analgesics, KCI, antibiotics, heparin) (focus on detection)
Patient Safety Practice: Use of computer monitoring for potential ADEs (Ch. 8)
Implementation Cost/Complexity: Medium

Patient Safety Problem: Surgical site infections
Patient Safety Practice: Use of supplemental perioperative oxygen (Ch. 20.3)
Implementation Cost/Complexity: Low

Patient Safety Problem: Morbidity and mortality
Patient Safety Practice: Changes in nursing staffing (Ch. 39)
Implementation Cost/Complexity: Medium

Patient Safety Problem: Missed or incomplete or not fully comprehended informed consent
Patient Safety Practice: Use of video or audio stimuli (Ch. 48)
Implementation Cost/Complexity: Low

Patient Safety Problem: Ventilator-associated pneumonia
Patient Safety Practice: Selective decontamination of digestive tract (Ch. 17.3)
Implementation Cost/Complexity: Low

Patient Safety Problem: Morbidity and mortality in ICU patients
Patient Safety Practice: Change in ICU structure-active management by intensivist (Ch. 38)
Implementation Cost/Complexity: High

Patient Safety Problem: Adverse events related to discontinuities in care
Patient Safety Practice: Information transfer between inpatient and outpatient pharmacy (Ch. 42.1)
Implementation Cost/Complexity: Medium

Patient Safety Problem: Hospital-acquired urinary tract infection
Patient Safety Practice: Use of silver alloy-coated catheters (Ch. 15.1)
Implementation Cost/Complexity: Low

Patient Safety Problem: Hospital-related delirium
Patient Safety Practice: Multi-component delirium prevention program (Ch. 28)
Implementation Cost/Complexity: Medium

Patient Safety Problem: Hospital-acquired complications (functional decline, mortality)
Patient Safety Practice: Geriatric evaluation and management unit (Ch. 30)
Implementation Cost/Complexity: High

Patient Safety Problem: Inadequate postoperative pain management
Patient Safety Practice: Non-pharmacologic interventions (e.g., relaxation, distraction)(Ch. 37.4)
Implementation Cost/Complexity: Low

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

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