Prepared by:
UCSF-Stanford Evidence-based Practice Center
Robert M. Wachter, M.D.
Project Director
Kathryn M. McDonald, M.M.
UCSF-Stanford EPC Coordinator
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.
File Name Description Software Version File Size __________________________________________________________________________________________________________ 01report.doc Microsoft WordR Document MS Word® 97 SR-1 3.9 MB 672 pages Contents: Title Page, Preface, Structured Abstract, Table of Contents, Summary, List of Contributors, Evidence Report: PART I. OVERVIEW Chapter 1. An Introduction to the Compendium 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 Chapter 3. Evidence-Based Review Methodology PART II. REPORTING AND RESPONDING TO PATIENT SAFETY PROBLEMS Chapter 4. Incident Reporting Chapter 5. Root Cause Analysis 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) Chapter 7. The Clinical Pharmacist's Role in Preventing Adverse Drug Events Chapter 8. Computer Adverse Drug Event (ADE) Detection and Alerts Chapter 9. Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants Chapter 10. Unit-Dose Drug Distribution Systems Chapter 11. Automated Medication Dispensing Devices Section B. Infection Control Chapter 12. Practices to Improve Handwashing Compliance Chapter 13. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections Chapter 14. Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance - Clostridium Difficile and Vancomycin-resistant Enterococcus (VRE) Chapter 15. Prevention of Nosocomial Urinary Tract Infections Subchapter 15.1. Use of Silver Alloy Urinary Catheters Subchapter 15.2. Use of Suprapubic Catheters Chapter 16. Prevention of Intravascular Catheter-Associated Infections 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 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 Chapter 19. Learning Curves for New Procedures - the Case of Laparoscopic Cholecystectomy Chapter 20. Prevention of Surgical Site Infections 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 Chapter 22. The Retained Surgical Sponge Chapter 23. Pre-Anesthesia Checklists To Improve Patient Safety Chapter 24. The Impact Of Intraoperative Monitoring On Patient Safety Chapter 25. Beta-blockers and Reduction of Perioperative Cardiac Events Section D. Safety Practices for Hospitalized or Institutionalized Elders Chapter 26. Prevention of Falls in Hospitalized and Institutionalized Older People 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 Chapter 28. Prevention of Delirium in Older Hospitalized Patients Chapter 29. Multidisciplinary Geriatric Consultation Services Chapter 30. Geriatric Evaluation and Management Units for Hospitalized Patients Section E. General Clinical Topics Chapter 31. Prevention of Venous Thromboembolism Chapter 32. Prevention of Contrast-Induced Nephropathy Chapter 33. Nutritional Support Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients Chapter 35. Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans Chapter 36. Pneumococcal Vaccination Prior to Hospital Discharge Subchapter 36.1. Vaccine Effectiveness Subchapter 36.2. Vaccine Delivery Methods Chapter 37. Pain Management 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 Chapter 39. Nurse Staffing, Models of Care Delivery, and Interventions Chapter 40. Promoting a Culture of Safety Section G. Systems Issues and Human Factors Chapter 41. Human Factors and Medical Devices 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 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 Subchapter 43.1. Bar Coding Subchapter 43.2. Strategies to Avoid Wrong-Site Surgery Chapter 44. Crew Resource Management and its Applications in Medicine Chapter 45. Simulator-Based Training and Patient Safety Chapter 46. Fatigue, Sleepiness, and Medical Errors Chapter 47. Safety During Transport of Critically Ill Patients Subchapter 47.1. Interhospital Transport Subchapter 47.2. Intrahospital Transport Section H. Role of the Patient Chapter 48. Procedures For Obtaining Informed Consent Chapter 49. Advance Planning For End-of-Life Care Chapter 50. Other Practices Related to Patient Participation PART IV. PROMOTING AND IMPLEMENTING SAFETY PRACTICES Chapter 51. Practice Guidelines Chapter 52. Critical Pathways Chapter 53. Clinical Decision Support Systems Chapter 54. Educational Techniques Used in Changing Provider Behavior Chapter 55. Legislation, Accreditation, and Market-Driven and Other Approaches to Improving Patient Safety PART V. ANALYZING THE PRACTICES Chapter 56. Methodology for Summarizing the Evidence for the Practices Chapter 57. Practices Rated by Strength of Evidence Chapter 58. Practices Rated by Research Priority Chapter 59. Listing of All Practices, Categorical Ratings, and Comments Subject Index Comments Section __________________________________________________________________________________________________________
AHRQ Publication No. 01-E058
Current as of July 2001
Internet Citation:
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. File Inventory, Evidence Report/Technology Assessment Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsftinv.htm
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