Addendum to Summary: Patient Safety Practices Rated by Strength of Evidence

After rating practices in terms of their potential impact, and on the strength of the evidence, the Editorial Board grouped them into 5 categories (Tables A-1 through A-5, adapted from Tables 57.1-57.5 of Making Health Care Safer: A Critical Analysis of Patient Safety Practices). These categorizations reflect the current state of the evidence.

If a practice that addresses a very common or severe patient safety problem receives a low rating on the impact/evidence scale, it may be because the strength of the evidence base is still weak because there have been few 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 the Tables, 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 of implementation (e.g., political or technical issues); "Medium," which represents 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 of implementation.

Several practices are not included in the tables because they were not rated. Among these are a set of practices that have long histories of use outside of medicine, but have not yet received adequate evaluation of their potential health care 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 of health care personnel (Chapter 46).
  • Napping Strategies for health care personnel (Chapter 46).
  • Incident Reporting (Chapter 4).

Table A-1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness *

ItemPatient Safety ProblemPatient Safety PracticeImplementation Cost/Complexity
1Venous thromboembolism (VTE)Appropriate VTE prophylaxis (Ch. 31)*Low
2Perioperative cardiac events in patients undergoing noncardiac surgeryUse of perioperative beta-blockers (Ch.25)Low
3Central venous catheter-related bloodstream infectionsUse of maximum sterile barriers during catheter insertion (Ch. 16.1)Low
4Surgical site infectionsAppropriate use of antibiotic prophylaxis (Ch. 20.1)Low
5Missed, incomplete or not fully comprehended informed consentAsking that patients recall and restate what they have been told during informed consent (Ch. 48)Low
6Ventilator-associated pneumoniaContinuous aspiration of subglottic secretions (CASS) (Ch. 17.2)Medium
7Pressure ulcersUse of pressure relieving bedding materials (Ch. 27)Medium
8Morbidity due to central venous catheter insertionUse of real-time ultrasound guidance during central line insertion (Ch. 21)High
9Adverse events related to chronic anticoagulation with warfarinPatient self management using home monitoring devices (Ch. 9)High
10Morbidity and mortality in post-surgical and critically ill patientsVarious nutritional strategies (Ch. 33)Medium
11Central venous catheter-related bloodstream infectionsAntibiotic-impregnated catheters (Ch. 16.2)Low

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

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

ItemPatient Safety ProblemPatient Safety PracticeImplementation Cost/Complexity
12Mortality associated with surgical proceduresLocalizing specific surgeries and procedures to high volume centers (Ch. 18)High (varies)
13Ventilator-associated pneumoniaSemi-recumbent positioning (Ch. 17.1)Low
14Falls and fall injuriesUse of hip protectors (Ch. 26.5)Low
15Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)Use of computer monitoring for potential ADEs (Ch. 8)Medium
16Surgical site infectionsUse of supplemental perioperative oxygen (Ch. 20.3)Low
17Morbidity and mortalityChanges in nursing staffing (Ch. 39)Medium
18Missed or incomplete or not fully comprehended informed consentUse of video or audio stimuli (Ch. 48)Low
19Ventilator-associated pneumoniaSelective decontamination of digestive tract (Ch. 17.3)Low
20Morbidity and mortality in ICU patientsChange in ICU structure—active management by intensivist (Ch. 38)High
21Adverse events related to discontinuities in careInformation transfer between inpatient and outpatient pharmacy (Ch. 42.1)Medium
22Hospital-acquired urinary tract infectionUse of silver alloy-coated catheters (Ch. 15.1)Low
23Hospital-related deliriumMulti-component delirium prevention program (Ch. 28)Medium
24Hospital-acquired complications (functional decline, mortality)Geriatric evaluation and management unit (Ch. 30)High
25Inadequate postoperative pain managementNon-pharmacologic interventions (e.g., relaxation, distraction) (Ch. 37.4)Low

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

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Table A-3. Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness *

ItemPatient Safety ProblemPatient Safety PracticeImplementation Cost/Complexity
26Medication errors and adverse drug events (ADEs) primarily related to ordering processComputerized physician order entry (CPOE) and clinical decision support (CDSS) (Ch. 6)High
27Failures to communicate significant abnormal results (e.g., pap smears)Protocols for notification of test results to patients (Ch. 42.4)Low
28Adverse events due to transportation of critically ill patients between health care facilitiesSpecialized teams for interhospital transport (Ch. 47)Medium
29Medication errors and adverse drug events (ADEs) related to ordering and monitoringClinical pharmacist consultation services (Ch. 7)Medium
30Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) (Ch. 13)Medium
31Surgical site infectionsPerioperative glucose control (Ch. 20.4)Medium
32Stress-related gastrointestinal bleedingH2 antagonists (Ch. 34)Low
33Pneumococcal pneumoniaMethods to increase pneumococcal vaccination rate (Ch. 36)Low
34Inadequate pain reliefAcute pain service (Ch. 37.2)Medium
35Adverse events related to anticoagulationAnticoagulation services and clinics for coumadin (Ch. 9)Medium
36Hospital-acquired infections due to antibiotic-resistant organismsLimitations placed on antibiotic use (Ch. 14)Low
37Hospital-acquired urinary tract infectionUse of suprapubic catheters (Ch. 15.2)High
38Contrast-induced renal failureHydration protocols with acetylcysteine (Ch. 32)Low
39Clinically significant misread radiographs and CT scans by non-radiologistsEducation interventions and continuous quality improvement strategies (Ch. 35)Low
40Missed or incomplete or not fully comprehended informed consentProvision of written informed consent information (Ch. 48)Low
41Failure to honor patient preferences for end-of-life careComputer-generated reminders to discuss advanced directives (Ch. 49)Medium (Varies)
42Adverse events related to anticoagulationProtocols for high-risk drugs: nomograms for heparin (Ch. 9)Low
43Ventilator-associated pneumoniaContinuous oscillation (Ch. 17.1)Medium
44Surgical site infectionsMaintenance of perioperative normothermia (Ch. 20.2)Low
45Restraint-related injury; FallsInterventions to reduce the use of physical restraints safely (Ch. 26,2)Medium
46FallsUse of bed alarms (Ch. 26.3)Medium
47Contrast-induced renal failureUse of low osmolar contrast media (Ch. 32)Medium

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

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Table A-4. Patient Safety Practices with Lower Impact and/or Strength of Evidence *

ItemPatient Safety ProblemPatient Safety PracticeImplementation Cost/Complexity
48Central venous catheter-related bloodstream infectionsCleaning site (povidone-iodine to chlorhexidine) (Ch. 16.3)Low
49Central venous catheter-related bloodstream infectionsUse of heparin (Ch. 16.4)Low
50Central venous catheter-related bloodstream infectionsTunneling short-term central venous catheters (Ch. 16.4)Medium
51Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)Geriatric consultation services (Ch. 29)High
52Inadequate pain relief in patients with abdominal pain in hospital patientsUse of analgesics in the patient with acute abdomen without compromising diagnostic accuracy (Ch. 37.1)Low
53Adverse events due to provider inexperience or unfamiliarity with certain procedures and situationsSimulator-based training (Ch. 45)Medium
54Adverse drug events (ADEs) in drug dispensing and/or administrationUse of automated medication dispensing devices (Ch. 11)Medium
55Hospital-acquired infectionsImprove handwashing compliance (via education/behavior change; sink technology and placement; washing substance) (Ch. 12)Low
56Failure to honor patient preferences for end-of-life careUse of physician order form for life-sustaining treatment (POLST) (Ch. 49)Low
57Adverse events due to patient misidentificationUse of bar coding (Ch. 43.1)Medium (Varies)
58Adverse drug events (ADEs) in dispensing medicationsUnit-dosing distribution system (Ch. 10)Low
59Critical events in anesthesiaIntraoperative monitoring of vital signs and oxygenation (Ch. 24)Low
60Adverse events during cross-coverageStandardized, structured sign-outs for physicians (Ch. 42.2)Low
61Adverse events related to team performance issuesApplications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) (Ch. 44)High
62Adverse events related to fatigue in health care workersLimiting individual provider's hours of service (Ch. 46)High

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

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Table A-5. Patient Safety Practices with Lowest Impact and/or Strength of Evidence*

ItemPatient Safety ProblemPatient Safety PracticeImplementation Cost/Complexity
63Complications due to anesthesia equipment failuresUse of pre-anesthesia checklists (Ch. 23)Low
64Adverse events related to information loss at dischargeUse of structured discharge summaries (Ch. 42.3)Low
65Surgical items left inside patientsCounting sharps, instruments and sponges (Ch. 22)Low
66Ventilator-associated pneumoniaUse of sucralfate (Ch. 26.4)Low
67Falls and fall-related injuriesUse of special flooring material in patient care areas (Ch. 26.4)Medium
68Performance of invasive diagnostic or therapeutic procedure on wrong body part"Sign your site" protocols (Ch. 43.2)Medium
69FallsUse of identification bracelets (Ch. 26.1)Low
70Contrast-induced renal failureHydration protocols with theophylline (Ch. 32)Low
71Adverse events due to transportation of critically ill patients within a hospitalMechanical rather than manual ventilation during transport (Ch. 47)Low
72Central venous catheter-related bloodstream infectionsChanging catheters routinely (Ch. 16.4)High
73Central venous catheter-related bloodstream infectionsRoutine antibiotic prophylaxis (Ch. 16.4)Medium

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

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Page last reviewed July 2001
Internet Citation: Addendum to Summary: Patient Safety Practices Rated by Strength of Evidence. July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/addendum.html