> ***Evidence Report/Technology Assessment***
>
> Number 43

**Making Health Care Safer: A Critical\
Analysis of Patient Safety Practices**

*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 five
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 there have been few evaluations, the evaluations have not
shown strong results, or there is a significant potential for harm from
the practice that needs to be considered. If the reason for the low
rating on the impact/evidence scale is the lack of evidence, the
practice is likely to show up at a high level on the research priority
scale (shown in chapter 58). 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. In this case,
"Low," corresponds to low cost and low complexity of implementation
(e.g., political or technical issues); "Medium," represents low to
medium cost and high complexity, *or* medium to high cost and low
complexity; and "High," 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 Follows on Next Page)

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

+------+----------------------+---------------------------+-----------+
| >    | > **Patient Safety   | > **Patient Safety        | > **Imple |
| **It | > Problem**          | > Practice**              | mentation |
| em** |                      |                           | >         |
|      |                      |                           |  Cost/Com |
|      |                      |                           | plexity** |
+------+----------------------+---------------------------+-----------+
| > 1  | > Venous             | > Appropriate VTE         | > Low     |
|      | > thromboembolism    | > prophylaxis (Ch. 31)\*  |           |
|      | > (VTE)              |                           |           |
+------+----------------------+---------------------------+-----------+
| > 2  | > Perioperative      | > Use of perioperative    | > Low     |
|      | > cardiac events in  | > beta-blockers (Ch.25)   |           |
|      | > patients           |                           |           |
|      | > undergoing         |                           |           |
|      | > noncardiac surgery |                           |           |
+------+----------------------+---------------------------+-----------+
| > 3  | > Central venous     | > Use of maximum sterile  | > Low     |
|      | > catheter-related   | > barriers during         |           |
|      | > bloodstream        | > catheter insertion (Ch. |           |
|      | > infections         | > 16.1)                   |           |
+------+----------------------+---------------------------+-----------+
| > 4  | > Surgical site      | > Appropriate use of      | > Low     |
|      | > infections         | > antibiotic prophylaxis  |           |
|      |                      | > (Ch. 20.1)              |           |
+------+----------------------+---------------------------+-----------+
| > 5  | > Missed, incomplete | > Asking that patients    | > Low     |
|      | > or not fully       | > recall and restate what |           |
|      | > comprehended       | > they have been told     |           |
|      | > informed consent   | > during informed consent |           |
|      |                      | > (Ch. 48)                |           |
+------+----------------------+---------------------------+-----------+
| > 6  | > V                  | > Continuous aspiration   | > Medium  |
|      | entilator-associated | > of subglottic           |           |
|      | > pneumonia          | > secretions (CASS) (Ch.  |           |
|      |                      | > 17.2)                   |           |
+------+----------------------+---------------------------+-----------+
| > 7  | > Pressure ulcers    | > Use of pressure         | > Medium  |
|      |                      | > relieving bedding       |           |
|      |                      | > materials (Ch. 27)      |           |
+------+----------------------+---------------------------+-----------+
| > 8  | > Morbidity due to   | > Use of real-time        | > High    |
|      | > central venous     | > ultrasound guidance     |           |
|      | > catheter insertion | > during central line     |           |
|      |                      | > insertion (Ch. 21)      |           |
+------+----------------------+---------------------------+-----------+
| > 9  | > Adverse events     | > Patient self management | > High    |
|      | > related to chronic | > using home monitoring   |           |
|      | > anticoagulation    | > devices (Ch. 9)         |           |
|      | > with warfarin      |                           |           |
+------+----------------------+---------------------------+-----------+
| > 10 | > Morbidity and      | > Various nutritional     | > Medium  |
|      | > mortality in       | > strategies (Ch. 33)     |           |
|      | > post-surgical and  |                           |           |
|      | > critically ill     |                           |           |
|      | > patients           |                           |           |
+------+----------------------+---------------------------+-----------+
| > 11 | > Central venous     | > Antibiotic-impregnated  | > Low     |
|      | > catheter-related   | > catheters (Ch. 16.2)    |           |
|      | > bloodstream        |                           |           |
|      | > infections         |                           |           |
+------+----------------------+---------------------------+-----------+

Abbreviations: Ch. = Chapter

\* Items within a particular category may not be in rank order. Item
numbers are for reference only.

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

+-----+-----------------------+---------------------------+------------+
| >   | **Patient Safety      | **Patient Safety          | **Impl     |
|  ** | Problem**             | Practice**                | ementation |
| Ite |                       |                           | Cost/Co    |
| m** |                       |                           | mplexity** |
+-----+-----------------------+---------------------------+------------+
| 12  | Mortality associated  | Localizing specific       | High       |
|     | with surgical         | surgeries and procedures  | (varies)   |
|     | procedures            | to high volume centers    |            |
|     |                       | (Ch. 18)                  |            |
+-----+-----------------------+---------------------------+------------+
| 13  | Ventilator-associated | Semi-recumbent            | Low        |
|     | pneumonia             | positioning (Ch. 17.1)    |            |
+-----+-----------------------+---------------------------+------------+
| 14  | Falls and fall        | Use of hip protectors     | Low        |
|     | injuries              | (Ch. 26.5)                |            |
+-----+-----------------------+---------------------------+------------+
| 15  | Adverse drug events   | Use of computer           | Medium     |
|     | (ADEs) related to     | monitoring for potential  |            |
|     | targeted classes      | ADEs (Ch. 8)              |            |
|     | (analgesics, KCl,     |                           |            |
|     | antibiotics, heparin) |                           |            |
|     | (focus on detection)  |                           |            |
+-----+-----------------------+---------------------------+------------+
| 16  | Surgical site         | Use of supplemental       | Low        |
|     | infections            | perioperative oxygen (Ch. |            |
|     |                       | 20.3)                     |            |
+-----+-----------------------+---------------------------+------------+
| 17  | Morbidity and         | Changes in nursing        | Medium     |
|     | mortality             | staffing (Ch. 39)         |            |
+-----+-----------------------+---------------------------+------------+
| 18  | Missed or incomplete  | Use of video or audio     | Low        |
|     | or not fully          | stimuli (Ch. 48)          |            |
|     | comprehended informed |                           |            |
|     | consent               |                           |            |
+-----+-----------------------+---------------------------+------------+
| 19  | Ventilator-associated | Selective decontamination | Low        |
|     | pneumonia             | of digestive tract (Ch.   |            |
|     |                       | 17.3)                     |            |
+-----+-----------------------+---------------------------+------------+
| 20  | Morbidity and         | Change in ICU             | High       |
|     | mortality in ICU      | structure---active        |            |
|     | patients              | management by intensivist |            |
|     |                       | (Ch. 38)                  |            |
+-----+-----------------------+---------------------------+------------+
| 21  | Adverse events        | Information transfer      | Medium     |
|     | related to            | between inpatient and     |            |
|     | discontinuities in    | outpatient pharmacy (Ch.  |            |
|     | care                  | 42.1)                     |            |
+-----+-----------------------+---------------------------+------------+
| 22  | Hospital-acquired     | Use of silver             | Low        |
|     | urinary tract         | alloy-coated catheters    |            |
|     | infection             | (Ch. 15.1)                |            |
+-----+-----------------------+---------------------------+------------+
| 23  | Hospital-related      | Multi-component delirium  | Medium     |
|     | delirium              | prevention program (Ch.   |            |
|     |                       | 28)                       |            |
+-----+-----------------------+---------------------------+------------+
| 24  | Hospital-acquired     | Geriatric evaluation and  | High       |
|     | complications         | management unit (Ch. 30)  |            |
|     | (functional decline,  |                           |            |
|     | mortality)            |                           |            |
+-----+-----------------------+---------------------------+------------+
| 25  | Inadequate            | Non-pharmacologic         | Low        |
|     | postoperative pain    | interventions (e.g.,      |            |
|     | management            | relaxation, distraction)  |            |
|     |                       | (Ch. 37.4)                |            |
+-----+-----------------------+---------------------------+------------+

Abbreviations: Ch. = Chapter

\* Items within a particular category may not be in rank order. Item
numbers are for reference only.

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

+-----+-----------------------+---------------------------+-----------+
| >   | **Patient Safety      | **Patient Safety          | **Imple   |
|  ** | Problem**             | Practice**                | mentation |
| Ite |                       |                           | Cost/Com  |
| m** |                       |                           | plexity** |
+-----+-----------------------+---------------------------+-----------+
| 26  | Medication errors and | Computerized physician    | High      |
|     | adverse drug events   | order entry (CPOE) and    |           |
|     | (ADEs) primarily      | clinical decision support |           |
|     | related to ordering   | (CDSS) (Ch. 6)            |           |
|     | process               |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 27  | Failures to           | Protocols for             | Low       |
|     | communicate           | notification of test      |           |
|     | significant abnormal  | results to patients (Ch.  |           |
|     | results (e.g., pap    | 42.4)                     |           |
|     | smears)               |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 28  | Adverse events due to | Specialized teams for     | Medium    |
|     | transportation of     | interhospital transport   |           |
|     | critically ill        | (Ch. 47)                  |           |
|     | patients between      |                           |           |
|     | health care           |                           |           |
|     | facilities            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 29  | Medication errors and | Clinical pharmacist       | Medium    |
|     | adverse drug events   | consultation services     |           |
|     | (ADEs) related to     | (Ch. 7)                   |           |
|     | ordering and          |                           |           |
|     | monitoring            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 30  | Serious nosocomial    | Barrier precautions (via  | Medium    |
|     | infections (e.g.,     | gowns & gloves; dedicated |           |
|     | vancomycin-resistant  | equipment; dedicated      |           |
|     | enterococcus*, C.     | personnel) (Ch. 13)       |           |
|     | difficile*)           |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 31  | Surgical site         | Perioperative glucose     | Medium    |
|     | infections            | control (Ch. 20.4)        |           |
+-----+-----------------------+---------------------------+-----------+
| 32  | Stress-related        | H~2~ antagonists (Ch. 34) | Low       |
|     | gastrointestinal      |                           |           |
|     | bleeding              |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 33  | Pneumococcal          | Methods to increase       | Low       |
|     | pneumonia             | pneumococcal vaccination  |           |
|     |                       | rate (Ch. 36)             |           |
+-----+-----------------------+---------------------------+-----------+
| 34  | Inadequate pain       | Acute pain service (Ch.   | Medium    |
|     | relief                | 37.2)                     |           |
+-----+-----------------------+---------------------------+-----------+
| 35  | Adverse events        | Anticoagulation services  | Medium    |
|     | related to            | and clinics for coumadin  |           |
|     | anticoagulation       | (Ch. 9)                   |           |
+-----+-----------------------+---------------------------+-----------+
| 36  | Hospital-acquired     | Limitations placed on     | Low       |
|     | infections due to     | antibiotic use (Ch. 14)   |           |
|     | antibiotic-resistant  |                           |           |
|     | organisms             |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 37  | Hospital-acquired     | Use of suprapubic         | High      |
|     | urinary tract         | catheters (Ch. 15.2)      |           |
|     | infection             |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 38  | Contrast-induced      | Hydration protocols with  | Low       |
|     | renal failure         | acetylcysteine (Ch. 32)   |           |
+-----+-----------------------+---------------------------+-----------+
| 39  | Clinically            | Education interventions   | Low       |
|     | significant misread   | and continuous quality    |           |
|     | radiographs and CT    | improvement strategies    |           |
|     | scans by              | (Ch. 35)                  |           |
|     | non-radiologists      |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 40  | Missed or incomplete  | Provision of written      | Low       |
|     | or not fully          | informed consent          |           |
|     | comprehended informed | information (Ch. 48)      |           |
|     | consent               |                           |           |
+-----+-----------------------+---------------------------+-----------+

  ------ ------------------------ ---------------------------- -----------
  41     Failure to honor patient Computer-generated reminders Medium
         preferences for          to discuss advanced          (Varies)
         end-of-life care         directives (Ch. 49)          

  42     Adverse events related   Protocols for high-risk      Low
         to anticoagulation       drugs: nomograms for heparin 
                                  (Ch. 9)                      

  43     Ventilator-associated    Continuous oscillation (Ch.  Medium
         pneumonia                17.1)                        

  44     Surgical site infections Maintenance of perioperative Low
                                  normothermia (Ch. 20.2)      

  45     Restraint-related        Interventions to reduce the  Medium
         injury; Falls            use of physical restraints   
                                  safely (Ch. 26,2)            

  46     Falls                    Use of bed alarms (Ch. 26.3) Medium

  47     Contrast-induced renal   Use of low osmolar contrast  Medium
         failure                  media (Ch. 32)               
  ------ ------------------------ ---------------------------- -----------

Abbreviations: Ch. = Chapter

\* Items within a particular category may not be in rank order. Item
numbers are for reference only.

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

+-----+-----------------------+---------------------------+-----------+
| >   | **Patient Safety      | **Patient Safety          | **Imple   |
|  ** | Problem**             | Practice**                | mentation |
| Ite |                       |                           | Cost/Com  |
| m** |                       |                           | plexity** |
+-----+-----------------------+---------------------------+-----------+
| 48  | Central venous        | Cleaning site             | Low       |
|     | catheter-related      | (povidone-iodine to       |           |
|     | bloodstream           | chlorhexidine) (Ch. 16.3) |           |
|     | infections            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 49  | Central venous        | Use of heparin (Ch. 16.4) | Low       |
|     | catheter-related      |                           |           |
|     | bloodstream           |                           |           |
|     | infections            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 50  | Central venous        | Tunneling short-term      | Medium    |
|     | catheter-related      | central venous catheters  |           |
|     | bloodstream           | (Ch. 16.4)                |           |
|     | infections            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 51  | Hospital-acquired     | Geriatric consultation    | High      |
|     | complications (e.g.,  | services (Ch. 29)         |           |
|     | falls, delirium,      |                           |           |
|     | functional decline,   |                           |           |
|     | mortality)            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 52  | Inadequate pain       | Use of analgesics in the  | Low       |
|     | relief in patients    | patient with acute        |           |
|     | with abdominal pain   | abdomen without           |           |
|     | in hospital patients  | compromising diagnostic   |           |
|     |                       | accuracy (Ch. 37.1)       |           |
+-----+-----------------------+---------------------------+-----------+
| 53  | Adverse events due to | Simulator-based training  | Medium    |
|     | provider inexperience | (Ch. 45)                  |           |
|     | or unfamiliarity with |                           |           |
|     | certain procedures    |                           |           |
|     | and situations        |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 54  | Adverse drug events   | Use of automated          | Medium    |
|     | (ADEs) in drug        | medication dispensing     |           |
|     | dispensing and/or     | devices (Ch. 11)          |           |
|     | administration        |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 55  | Hospital-acquired     | Improve handwashing       | Low       |
|     | infections            | compliance (via           |           |
|     |                       | education/behavior        |           |
|     |                       | change; sink technology   |           |
|     |                       | and placement; washing    |           |
|     |                       | substance) (Ch. 12)       |           |
+-----+-----------------------+---------------------------+-----------+
| 56  | Failure to honor      | Use of physician order    | Low       |
|     | patient preferences   | form for life-sustaining  |           |
|     | for end-of-life care  | treatment (POLST) (Ch.    |           |
|     |                       | 49)                       |           |
+-----+-----------------------+---------------------------+-----------+
| 57  | Adverse events due to | Use of bar coding (Ch.    | Medium    |
|     | patient               | 43.1)                     | (Varies)  |
|     | misidentification     |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 58  | Adverse drug events   | Unit-dosing distribution  | Low       |
|     | (ADEs) in dispensing  | system (Ch. 10)           |           |
|     | medications           |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 59  | Critical events in    | Intraoperative monitoring | Low       |
|     | anesthesia            | of vital signs and        |           |
|     |                       | oxygenation (Ch. 24)      |           |
+-----+-----------------------+---------------------------+-----------+
| 60  | Adverse events during | Standardized, structured  | Low       |
|     | cross-coverage        | sign-outs for physicians  |           |
|     |                       | (Ch. 42.2)                |           |
+-----+-----------------------+---------------------------+-----------+
| 61  | Adverse events        | Applications of           | High      |
|     | related to team       | aviation-style crew       |           |
|     | performance issues    | resource management       |           |
|     |                       | (e.g., Anesthesia Crisis  |           |
|     |                       | Management; MedTeams)     |           |
|     |                       | (Ch. 44)                  |           |
+-----+-----------------------+---------------------------+-----------+
| 62  | Adverse events        | Limiting individual       | High      |
|     | related to fatigue in | provider's hours of       |           |
|     | health care workers   | service (Ch. 46)          |           |
+-----+-----------------------+---------------------------+-----------+

Abbreviations: Ch. = Chapter

\* Items within a particular category may not be in rank order. Item
numbers are for reference only.

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

+-----+-----------------------+---------------------------+-----------+
| >   | **Patient Safety      | **Patient Safety          | **Imple   |
|  ** | Problem**             | Practice**                | mentation |
| Ite |                       |                           | Cost/Com  |
| m** |                       |                           | plexity** |
+-----+-----------------------+---------------------------+-----------+
| 63  | Complications due to  | Use of pre-anesthesia     | Low       |
|     | anesthesia equipment  | checklists (Ch. 23)       |           |
|     | failures              |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 64  | Adverse events        | Use of structured         | Low       |
|     | related to            | discharge summaries (Ch.  |           |
|     | information loss at   | 42.3)                     |           |
|     | discharge             |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 65  | Surgical items left   | Counting sharps,          | Low       |
|     | inside patients       | instruments and sponges   |           |
|     |                       | (Ch. 22)                  |           |
+-----+-----------------------+---------------------------+-----------+
| 66  | Ventilator-associated | Use of sucralfate (Ch.    | Low       |
|     | pneumonia             | 26.4)                     |           |
+-----+-----------------------+---------------------------+-----------+
| 67  | Falls and             | Use of special flooring   | Medium    |
|     | fall-related injuries | material in patient care  |           |
|     |                       | areas (Ch. 26.4)          |           |
+-----+-----------------------+---------------------------+-----------+
| 68  | Performance of        | "Sign your site"          | Medium    |
|     | invasive diagnostic   | protocols (Ch. 43.2)      |           |
|     | or therapeutic        |                           |           |
|     | procedure on wrong    |                           |           |
|     | body part             |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 69  | Falls                 | Use of identification     | Low       |
|     |                       | bracelets (Ch. 26.1)      |           |
+-----+-----------------------+---------------------------+-----------+
| 70  | Contrast-induced      | Hydration protocols with  | Low       |
|     | renal failure         | theophylline (Ch. 32)     |           |
+-----+-----------------------+---------------------------+-----------+
| 71  | Adverse events due to | Mechanical rather than    | Low       |
|     | transportation of     | manual ventilation during |           |
|     | critically ill        | transport (Ch. 47)        |           |
|     | patients within a     |                           |           |
|     | hospital              |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 72  | Central venous        | Changing catheters        | High      |
|     | catheter-related      | routinely (Ch. 16.4)      |           |
|     | bloodstream           |                           |           |
|     | infections            |                           |           |
+-----+-----------------------+---------------------------+-----------+
| 73  | Central venous        | Routine antibiotic        | Medium    |
|     | catheter-related      | prophylaxis (Ch. 16.4)    |           |
|     | bloodstream           |                           |           |
|     | infections            |                           |           |
+-----+-----------------------+---------------------------+-----------+

Abbreviations: Ch. = Chapter

\* Items within a particular category may not be in rank order. Item
numbers are for reference only.

AHRQ Pub. No. 01-E057b

July 2001

ISSN 1530-440X