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Chapter 57. Practices Rated by Strength of Evidence

After rating practices on a metric for potential impact, and on the strength of the evidence, we grouped them into 5 categories (Tables 57.1-57.5). These categorizations reflect the current state of the evidence. If a practice that addresses a highly prevalent or severe patient safety target receives a low rating on the impact/evidence scale, it may be because the strength of the evidence base is still weak due to lack of 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 Tables 57.1 through 57.5, 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 (e.g., political, technical); "Medium," which signifies 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.

Several practices are not included in the tables because they were not rated. This set of practices have long histories of use outside of medicine, but have not yet received enough evaluations for their potential healthcare 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 (Chapter 46).
  • Napping Strategies (Chapter 46).

Table 57.1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness

ChapterPatient Safety TargetPatient Safety PracticeImplementation Cost/Complex
31Venous thromboembolism (VTE)Appropriate VTE prophylaxisLow
25Perioperative cardiac events in patients undergoing noncardiac surgeryUse of perioperative beta-blockersLow
16.1Central venous catheter-related bloodstream infectionsUse of maximum sterile barriers during catheter insertionLow
20.1Surgical site infectionsAppropriate use of antibiotic prophylaxisLow
48Missed, incomplete or not fully comprehended informed consentAsking that patients recall and restate what they have been told during informed consentLow
17.2Ventilator-associated pneumoniaContinuous aspiration of subglottic secretions (CASS)Medium
27Pressure ulcersUse of pressure relieving bedding materialsMedium
21Morbidity due to central venous catheter insertionUse of real-time ultrasound guidance during central line insertionHigh
9Adverse events related to chronic anticoagulation with warfarinPatient self management using home monitoring devicesHigh
33Morbidity and mortality in post-surgical and critically ill patientsVarious nutritional strategiesMedium
16.2Central venous catheter-related bloodstream infectionsAntibiotic-impregnated cathetersLow

Table 57.2 Patient Safety Practices with High Strength of Evidence Regarding their Impact and Effectiveness

ChapterPatient Safety TargetPatient Safety PracticeImplementation Cost/Complex
18Mortality associated with surgical proceduresLocalizing specific surgeries and procedures to high volume centersHigh (varies)
17.1Ventilator-associated pneumoniaSemi-recumbent positioningLow
26.5Falls and fall injuriesUse of hip protectorsLow
8Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)Use of computer monitoring for potential ADEsMedium
20.3Surgical site infectionsUse of supplemental perioperative oxygenLow
39Morbidity and mortalityChanges in nursing staffingMedium
48Missed or incomplete or not fully comprehended informed consentUse of video or audio stimuliLow
17.3Ventilator-associated pneumoniaSelective decontamination of digestive tractLow
38Morbidity and mortality in ICU patientsChange in ICU structure—active management by intensivistHigh
42.1Adverse events related to discontinuities in careInformation transfer between inpatient and outpatient pharmacyMedium
15.1Hospital-acquired urinary tract infectionUse of silver alloy-coated cathetersLow
28Hospital-related deliriumMulti-component delirium prevention programMedium
30Hospital-acquired complications (functional decline, mortality)Geriatric evaluation and management unitHigh
37.4Inadequate postoperative pain managementNon-pharmacologic interventions (e.g., relaxation, distraction)Low

Table 57.3 Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness

ChapterPatient Safety TargetPatient Safety PracticeImplementation Cost/Complex
6Medication errors and adverse drug events (ADEs) primarily related to ordering processComputerized physician order entry (CPOE) and clinical decision support (CDSS)High
42.4Failures to communicate significant abnormal results (e.g., pap smears)Protocols for notification of test results to patientsLow
47Adverse events due to transportation of critically ill patients between healthcare facilitiesSpecialized teams for interhospital transportMedium
7Medication errors and adverse drug events (ADEs) related to ordering and monitoringClinical pharmacist consultation servicesMedium
13Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel)Medium
20.4Surgical site infectionsPerioperative glucose controlMedium
34Stress-related gastrointestinal bleedingH2 antagonistsLow
36Pneumococcal pneumoniaMethods to increase pneumococcal vaccination rateLow
37.2Inadequate pain reliefAcute pain serviceMedium
9Adverse events related to anticoagulationAnticoagulation services and clinics for coumadinMedium
14Hospital-acquired infections due to antibiotic-resistant organismsLimitations placed on antibiotic useLow
15.2Hospital-acquired urinary tract infectionUse of suprapubic cathetersHigh
32Contrast-induced renal failureHydration protocols with acetylcysteineLow
35Clinically significant misread radiographs and CT scans by non-radiologistsEducation interventions and continuous quality improvement strategiesLow
48Missed or incomplete or not fully comprehended informed consentProvision of written informed consent informationLow
49Failure to honor patient preferences for end-of-life careComputer-generated reminders to discuss advanced directivesMedium (Varies)
9Adverse events related to anticoagulationProtocols for high-risk drugs: nomograms for heparinLow
17.1Ventilator-associated pneumoniaContinuous oscillationMedium
20.2Surgical site infectionsMaintenance of perioperative normothermiaLow
26.2Restraint-related injury; FallsInterventions to reduce the use of physical restraints safelyMedium
26.3FallsUse of bed alarmsMedium
32Contrast-induced renal failureUse of low osmolar contrast mediaMedium

Table 57.4 Patient Safety Practices with Lower Impact and/or Strength of Evidence

ChapterPatient Safety TargetPatient Safety PracticeImplementation Cost/Complex
16.3Central venous catheter-related bloodstream infectionsCleaning site (povidone-iodine to chlorhexidine)Low
16.4Central venous catheter-related bloodstream infectionsUse of heparinLow
16.4Central venous catheter-related bloodstream infectionsTunneling short-term central venous cathetersMedium
29Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)Geriatric consultation servicesHigh
37.1Inadequate pain relief in patients with abdominal pain in hospital patientsUse of analgesics in the patient with acute abdomen without compromising diagnostic accuracyLow
45Adverse events due to provider inexperience or unfamiliarity with certain procedures and situationsSimulator-based trainingMedium
11Adverse drug events (ADEs) in drug dispensing and/or administrationUse of automated medication dispensing devicesMedium
12Hospital-acquired infectionsImprove handwashing compliance (via education/behavior change; sink technology and placement; washing substance)Low
49Failure to honor patient preferences for end-of-life careUse of physician order form for life-sustaining treatment (POLST)Low
43.1Adverse events due to patient misidentificationUse of bar codingMedium (Varies)
10Adverse drug events (ADEs) in dispensing medicationsUnit-dosing distribution systemLow
24Critical events in anesthesiaIntraoperative monitoring of vital signs and oxygenationLow
42.2Adverse events during cross-coverageStandardized, structured sign-outs for physiciansLow
44Adverse events related to team performance issuesApplications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams)High
46Adverse events related to fatigue in healthcare workersLimiting individual provider's hours of serviceHigh

57.5 Patient Safety Practices with Lowest Impact and/or Strength of Evidence

ChapterPatient Safety TargetPatient Safety PracticeImplementation Cost/Complex
23Complications due to anesthesia equipment failuresUse of pre-anesthesia checklistsLow
42.3Adverse events related to information loss at dischargeUse of structured discharge summariesLow
22Surgical items left inside patientsCounting sharps, instruments and spongesLow
17.4Ventilator-associated pneumoniaUse of sucralfateLow
26.4Falls and fall-related injuriesUse of special flooring material in patient care areasMedium
43.2Performance of invasive diagnostic or therapeutic procedure on wrong body partProtocolsMedium
26.1FallsUse of identification braceletsLow
32Contrast-induced renal failureHydration protocols with theophyllineLow
47Adverse events due to transportation of critically ill patients within a hospitalMechanical rather than manual ventilation during transportLow
16.4Central venous catheter-related bloodstream infectionsChanging catheters routinelyHigh
16.4Central venous catheter-related bloodstream infectionsRoutine antibiotic prophylaxisMedium

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Page last reviewed July 2001
Internet Citation: Chapter 57. Practices Rated by Strength of Evidence. July 2001. Agency for Healthcare Research and Quality, Rockville, MD.