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A Critical Analysis of Patient Safety Practices

Evidence Report/Technology Assessment, No. 43

Please Note: The evidence report this summary was derived from has not been updated within the past 5 years and is therefore no longer considered current. It is maintained for archival purposes only.

Prepared for:
Agency for Healthcare Research and Quality, Contract No. 290-97-0013

Prepared by:
University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center

Project Director: Robert M. Wachter, M.D.
UCSF-Stanford EPC Coordinator: Kathryn M. McDonald, M.M.

Editorial Board
Kaveh G. Shojania, M.D. (UCSF)
Bradford W. Duncan, M.D. (Stanford)
Kathryn M. McDonald, M.M. (Stanford)
Robert M. Wachter, M.D. (UCSF)

Managing Editor: Amy J. Markowitz, J.D.

PDF Files are available for the Full Report (1.6 MB) and also for each chapter. PDF Help.


Front Matter (PDF File, 41 KB)
Structured Abstract
Executive Summary

Part I. Overview
Chapter 1. An Introduction to the Compendium (PDF File, 38 KB)
   Subchapter 1.1. General Overview
   Subchapter 1.2. How to Use this Compendium
   Subchapter 1.3. Acknowledgments
Chapter 2. Drawing on Safety Practices from Outside Healthcare (PDF File, 15 KB)
Chapter 3. Evidence-Based Review Methodology (PDF File, 26 KB)

Part II. Reporting and Responding to Patient Safety Problems
Chapter 4. Incident Reporting (PDF File, 35 KB)
Chapter 5. Root Cause Analysis (PDF File, 19 KB)

Part III. Patient Safety Practices & Targets
Section A. Adverse Drug Events (ADEs)
Chapter 6. Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs) (PDF File, 34 KB)
Chapter 7. The Clinical Pharmacist's Role in Preventing Adverse Drug Events (PDF File, 22 KB)
Chapter 8. Computer Adverse Drug Event (ADE) Detection and Alerts (PDF File, 20 KB)
Chapter 9. Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants (PDF File, 37 KB)
Chapter 10. Unit-Dose Drug Distribution Systems (PDF File, 23 KB)
Chapter 11. Automated Medication Dispensing Devices (PDF File, 20 KB)

Section B. Infection Control
Chapter 12. Practices to Improve Handwashing Compliance (PDF File, 23 KB)
Chapter 13. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections (PDF File, 41 KB)
Chapter 14. Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance—Clostridium Difficile and Vancomycin-resistant Enterococcus (VRE) (PDF File, 24 KB)
Chapter 15. Prevention of Nosocomial Urinary Tract Infections (PDF File, 43 KB)
   Subchapter 15.1. Use of Silver Alloy Urinary Catheters
   Subchapter 15.2. Use of Suprapubic Catheters
Chapter 16. Prevention of Intravascular Catheter-Associated Infections (PDF File, 57 KB)
   Subchapter 16.1. Use of Maximum Barrier Precautions during Central Venous Catheter Insertion
   Subchapter 16.2. Use of Central Venous Catheters Coated with Antibacterial or Antiseptic Agents
   Subchapter 16.3. Use of Chlorhexidine Gluconate at the Central Venous Catheter Insertion Site
   Subchapter 16.4. Other Practices
Chapter 17. Prevention of Ventilator-Associated Pneumonia (VAP) (PDF File, 49 KB)
   Subchapter 17.1. Patient Positioning: Semi-recumbent Positioning and Continuous Oscillation
   Subchapter 17.2. Continuous Aspiration of Subglottic Secretions
   Subchapter 17.3. Selective Digestive Tract Decontamination
   Subchapter 17.4. Sucralfate and Prevention of VAP

Section C. Surgery, Anesthesia, and Perioperative Medicine
Chapter 18. Localizing Care to High-Volume Centers (PDF File, 24 KB)
Chapter 19. Learning Curves for New Procedures—the Case of Laparoscopic Cholecystectomy (PDF File, 24 KB)
Chapter 20. Prevention of Surgical Site Infections (PDF File, 64 KB)
   Subchapter 20.1 Prophylactic Antibiotics
   Subchapter 20.2. Perioperative Normothermia
   Subchapter 20.3. Supplemental Perioperative Oxygen
   Subchapter 20.4. Perioperative Glucose Control
Chapter 21. Ultrasound Guidance of Central Vein Catheterization (PDF File, 27 KB)
Chapter 22. The Retained Surgical Sponge (PDF File, 10 KB)
Chapter 23: Pre-Anesthesia Checklists To Improve Patient Safety (PDF File, 15 KB)
Chapter 24. The Impact Of Intraoperative Monitoring On Patient Safety (PDF File, 17 KB)
Chapter 25. Beta-blockers and Reduction of Perioperative Cardiac Events (PDF File, 26 KB)

Section D. Safety Practices for Hospitalized or Institutionalized Elders
Chapter 26. Prevention of Falls in Hospitalized and Institutionalized Older People (PDF File, 51 KB)
   Subchapter 26.1. Identification Bracelets for High-Risk Patients
   Subchapter 26.2. Interventions that Decrease the Use of Physical Restraints
   Subchapter 26.3. Bed Alarms
   Subchapter 26.4. Special Hospital Flooring Materials to Reduce Injuries from Patient Falls
   Subchapter 26.5. Hip Protectors to Prevent Hip Fracture
Chapter 27. Prevention of Pressure Ulcers in Older Patients (PDF File, 20 KB)
Chapter 28. Prevention of Delirium in Older Hospitalized Patients (PDF File, 20 KB)
Chapter 29. Multidisciplinary Geriatric Consultation Services (PDF File, 25 KB)
Chapter 30. Geriatric Evaluation and Management Units for Hospitalized Patients (PDF File, 42 KB)

Section E. General Clinical Topics
Chapter 31. Prevention of Venous Thromboembolism (PDF File, 45 KB)
Chapter 32. Prevention of Contrast-Induced Nephropathy (PDF File, 27 KB)
Chapter 33. Nutritional Support (PDF File, 27 KB)
Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients (PDF File, 20 KB)
Chapter 35. Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans (PDF File, 29 KB)
Chapter 36. Pneumococcal Vaccination Prior to Hospital Discharge (PDF File, 31 KB)
Chapter 37. Pain Management (PDF File, 40 KB)
   Subchapter 37.1. Use of Analgesics in the Acute Abdomen
   Subchapter 37.2. Acute Pain Services
   Subchapter 37.3. Prophylactic Antiemetics During Patient-controlled Analgesia Therapy
   Subchapter 37.4. Non-pharmacologic Interventions for Postoperative Plan

Section F. Organization, Structure, and Culture
Chapter 38. "Closed" Intensive Care Units and Other Models of Care for Critically Ill Patients (PDF File, 28 KB)
Chapter 39. Nurse Staffing, Models of Care Delivery, and Interventions (PDF File, 66 KB)
Chapter 40. Promoting a Culture of Safety (PDF File, 31 KB)

Section G. Systems Issues and Human Factors
Chapter 41. Human Factors and Medical Devices (PDF File, 38 KB)
   Subchapter 41.1. The Use of Human Factors in Reducing Device-related Medical Errors
   Subchapter 41.2. Refining the Performance of Medical Device Alarms
   Subchapter 41.3. Equipment Checklists in Anesthesia
Chapter 42. Information Transfer (PDF File, 45 KB)
   Subchapter 42.1. Information Transfer Between Inpatient and Outpatient Pharmacies
   Subchapter 42.2. Sign-Out Systems for Cross-Coverage
   Subchapter 42.3. Discharge Summaries and Follow-up
   Subchapter 42.4. Notifying Patients of Abnormal Results
Chapter 43. Prevention of Misidentifications (PDF File, 41 KB)
   Subchapter 43.1. Bar Coding
   Subchapter 43.2. Strategies to Avoid Wrong-Site Surgery
Chapter 44. Crew Resource Management and its Applications in Medicine (PDF File, 30 KB)
Chapter 45. Simulator-Based Training and Patient Safety (PDF File, 26 KB)
Chapter 46. Fatigue, Sleepiness, and Medical Errors (PDF File, 47 KB)
Chapter 47. Safety During Transportation of Critically Ill Patients (PDF File, 28 KB)
   Subchapter 47.1. Interhospital Transport
   Subchapter 47.2. Intrahospital Transport

Section H. Role of the Patient
Chapter 48. Procedures For Obtaining Informed Consent (PDF File, 29 KB)
Chapter 49. Advance Planning For End-of-Life Care (PDF File, 36 KB)
Chapter 50. Other Practices Related to Patient Participation (PDF File, 15 KB)

Part IV. Promoting And Implementing Safety Practices
Chapter 51. Practice Guidelines (PDF File, 19 KB)
Chapter 52. Critical Pathways (PDF File, 21 KB)
Chapter 53. Clinical Decision Support Systems (PDF File, 17 KB)
Chapter 54. Educational Techniques Used in Changing Provider Behavior (PDF File, 17 KB)
Chapter 55. Legislation, Accreditation, and Market-Driven and Other Approaches to Improving Patient Safety (PDF File, 26 KB)

Part V. Analyzing The Practices
Chapter 56. Methodology for Summarizing the Evidence for the Practices (PDF File, 21 KB)
Chapter 57. Practices Rated by Strength of Evidence (PDF File, 24 KB)
Chapter 58. Practices Rated by Research Priority (PDF File, 21 KB)
Chapter 59. Listing of All Practices, Categorical Ratings, and Comments (PDF File, 55 KB)

Back Matter
Contributors (PDF File, 10 KB)
Index (PDF File, 23 KB)

AHRQ Publication No. 01-E058
Current as of July 2001


The information on this page is archived and provided for reference purposes only.


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