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

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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 *

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Item	Patient Safety Problem	Patient Safety Practice	Implementation Cost/Complexity
1	Venous thromboembolism (VTE)	Appropriate VTE prophylaxis (Ch. 31)*	Low
2	Perioperative cardiac events in patients undergoing noncardiac surgery	Use of perioperative beta-blockers (Ch.25)	Low
3	Central venous catheter-related bloodstream infections	Use of maximum sterile barriers during catheter insertion (Ch. 16.1)	Low
4	Surgical site infections	Appropriate use of antibiotic prophylaxis (Ch. 20.1)	Low
5	Missed, incomplete or not fully comprehended informed consent	Asking that patients recall and restate what they have been told during informed consent (Ch. 48)	Low
6	Ventilator-associated pneumonia	Continuous aspiration of subglottic secretions (CASS) (Ch. 17.2)	Medium
7	Pressure ulcers	Use of pressure relieving bedding materials (Ch. 27)	Medium
8	Morbidity due to central venous catheter insertion	Use of real-time ultrasound guidance during central line insertion (Ch. 21)	High
9	Adverse events related to chronic anticoagulation with warfarin	Patient self management using home monitoring devices (Ch. 9)	High
10	Morbidity and mortality in post-surgical and critically ill patients	Various nutritional strategies (Ch. 33)	Medium
11	Central venous catheter-related bloodstream infections	Antibiotic-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*

Item	Patient Safety Problem	Patient Safety Practice	Implementation Cost/Complexity
12	Mortality associated with surgical procedures	Localizing specific surgeries and procedures to high volume centers (Ch. 18)	High (varies)
13	Ventilator-associated pneumonia	Semi-recumbent positioning (Ch. 17.1)	Low
14	Falls and fall injuries	Use of hip protectors (Ch. 26.5)	Low
15	Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)	Use of computer monitoring for potential ADEs (Ch. 8)	Medium
16	Surgical site infections	Use of supplemental perioperative oxygen (Ch. 20.3)	Low
17	Morbidity and mortality	Changes in nursing staffing (Ch. 39)	Medium
18	Missed or incomplete or not fully comprehended informed consent	Use of video or audio stimuli (Ch. 48)	Low
19	Ventilator-associated pneumonia	Selective decontamination of digestive tract (Ch. 17.3)	Low
20	Morbidity and mortality in ICU patients	Change in ICU structure—active management by intensivist (Ch. 38)	High
21	Adverse events related to discontinuities in care	Information transfer between inpatient and outpatient pharmacy (Ch. 42.1)	Medium
22	Hospital-acquired urinary tract infection	Use of silver alloy-coated catheters (Ch. 15.1)	Low
23	Hospital-related delirium	Multi-component delirium prevention program (Ch. 28)	Medium
24	Hospital-acquired complications (functional decline, mortality)	Geriatric evaluation and management unit (Ch. 30)	High
25	Inadequate postoperative pain management	Non-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 *

Item	Patient Safety Problem	Patient Safety Practice	Implementation Cost/Complexity
26	Medication errors and adverse drug events (ADEs) primarily related to ordering process	Computerized physician order entry (CPOE) and clinical decision support (CDSS) (Ch. 6)	High
27	Failures to communicate significant abnormal results (e.g., pap smears)	Protocols for notification of test results to patients (Ch. 42.4)	Low
28	Adverse events due to transportation of critically ill patients between health care facilities	Specialized teams for interhospital transport (Ch. 47)	Medium
29	Medication errors and adverse drug events (ADEs) related to ordering and monitoring	Clinical pharmacist consultation services (Ch. 7)	Medium
30	Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)	Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) (Ch. 13)	Medium
31	Surgical site infections	Perioperative glucose control (Ch. 20.4)	Medium
32	Stress-related gastrointestinal bleeding	H2 antagonists (Ch. 34)	Low
33	Pneumococcal pneumonia	Methods to increase pneumococcal vaccination rate (Ch. 36)	Low
34	Inadequate pain relief	Acute pain service (Ch. 37.2)	Medium
35	Adverse events related to anticoagulation	Anticoagulation services and clinics for coumadin (Ch. 9)	Medium
36	Hospital-acquired infections due to antibiotic-resistant organisms	Limitations placed on antibiotic use (Ch. 14)	Low
37	Hospital-acquired urinary tract infection	Use of suprapubic catheters (Ch. 15.2)	High
38	Contrast-induced renal failure	Hydration protocols with acetylcysteine (Ch. 32)	Low
39	Clinically significant misread radiographs and CT scans by non-radiologists	Education interventions and continuous quality improvement strategies (Ch. 35)	Low
40	Missed or incomplete or not fully comprehended informed consent	Provision of written informed consent information (Ch. 48)	Low
41	Failure to honor patient preferences for end-of-life care	Computer-generated reminders to discuss advanced directives (Ch. 49)	Medium (Varies)
42	Adverse events related to anticoagulation	Protocols for high-risk drugs: nomograms for heparin (Ch. 9)	Low
43	Ventilator-associated pneumonia	Continuous oscillation (Ch. 17.1)	Medium
44	Surgical site infections	Maintenance of perioperative normothermia (Ch. 20.2)	Low
45	Restraint-related injury; Falls	Interventions to reduce the use of physical restraints safely (Ch. 26,2)	Medium
46	Falls	Use of bed alarms (Ch. 26.3)	Medium
47	Contrast-induced renal failure	Use 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 *

Item	Patient Safety Problem	Patient Safety Practice	Implementation Cost/Complexity
48	Central venous catheter-related bloodstream infections	Cleaning site (povidone-iodine to chlorhexidine) (Ch. 16.3)	Low
49	Central venous catheter-related bloodstream infections	Use of heparin (Ch. 16.4)	Low
50	Central venous catheter-related bloodstream infections	Tunneling short-term central venous catheters (Ch. 16.4)	Medium
51	Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)	Geriatric consultation services (Ch. 29)	High
52	Inadequate pain relief in patients with abdominal pain in hospital patients	Use of analgesics in the patient with acute abdomen without compromising diagnostic accuracy (Ch. 37.1)	Low
53	Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations	Simulator-based training (Ch. 45)	Medium
54	Adverse drug events (ADEs) in drug dispensing and/or administration	Use of automated medication dispensing devices (Ch. 11)	Medium
55	Hospital-acquired infections	Improve handwashing compliance (via education/behavior change; sink technology and placement; washing substance) (Ch. 12)	Low
56	Failure to honor patient preferences for end-of-life care	Use of physician order form for life-sustaining treatment (POLST) (Ch. 49)	Low
57	Adverse events due to patient misidentification	Use of bar coding (Ch. 43.1)	Medium (Varies)
58	Adverse drug events (ADEs) in dispensing medications	Unit-dosing distribution system (Ch. 10)	Low
59	Critical events in anesthesia	Intraoperative monitoring of vital signs and oxygenation (Ch. 24)	Low
60	Adverse events during cross-coverage	Standardized, structured sign-outs for physicians (Ch. 42.2)	Low
61	Adverse events related to team performance issues	Applications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) (Ch. 44)	High
62	Adverse events related to fatigue in health care workers	Limiting 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*

Item	Patient Safety Problem	Patient Safety Practice	Implementation Cost/Complexity
63	Complications due to anesthesia equipment failures	Use of pre-anesthesia checklists (Ch. 23)	Low
64	Adverse events related to information loss at discharge	Use of structured discharge summaries (Ch. 42.3)	Low
65	Surgical items left inside patients	Counting sharps, instruments and sponges (Ch. 22)	Low
66	Ventilator-associated pneumonia	Use of sucralfate (Ch. 26.4)	Low
67	Falls and fall-related injuries	Use of special flooring material in patient care areas (Ch. 26.4)	Medium
68	Performance of invasive diagnostic or therapeutic procedure on wrong body part	"Sign your site" protocols (Ch. 43.2)	Medium
69	Falls	Use of identification bracelets (Ch. 26.1)	Low
70	Contrast-induced renal failure	Hydration protocols with theophylline (Ch. 32)	Low
71	Adverse events due to transportation of critically ill patients within a hospital	Mechanical rather than manual ventilation during transport (Ch. 47)	Low
72	Central venous catheter-related bloodstream infections	Changing catheters routinely (Ch. 16.4)	High
73	Central venous catheter-related bloodstream infections	Routine 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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AHRQ Publication No. 01-E057b
Current as of July 2001

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Internet Citation:

Patient Safety Practices Rated by Strength of Evidence. Addendum to Summary. July 2001. AHRQ Publication No. 01-E057b. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/clinic/ptsafety/addend.htm

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