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:
Table 57.1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness
| Chapter | Patient Safety Target | Patient Safety Practice | Implementation Cost/Complex |
| 31 | Venous thromboembolism (VTE) | Appropriate VTE prophylaxis | Low |
| 25 | Perioperative cardiac events in patients undergoing noncardiac surgery | Use of perioperative beta-blockers | Low |
| 16.1 | Central venous catheter-related bloodstream infections | Use of maximum sterile barriers during catheter insertion | Low |
| 20.1 | Surgical site infections | Appropriate use of antibiotic prophylaxis | Low |
| 48 | Missed, incomplete or not fully comprehended informed consent | Asking that patients recall and restate what they have been told during informed consent | Low |
| 17.2 | Ventilator-associated pneumonia | Continuous aspiration of subglottic secretions (CASS) | Medium |
| 27 | Pressure ulcers | Use of pressure relieving bedding materials | Medium |
| 21 | Morbidity due to central venous catheter insertion | Use of real-time ultrasound guidance during central line insertion | High |
| 9 | Adverse events related to chronic anticoagulation with warfarin | Patient self management using home monitoring devices | High |
| 33 | Morbidity and mortality in post-surgical and critically ill patients | Various nutritional strategies | Medium |
| 16.2 | Central venous catheter-related bloodstream infections | Antibiotic-impregnated catheters | Low |
Table 57.2 Patient Safety Practices with High Strength of Evidence Regarding their Impact and Effectiveness
| Chapter | Patient Safety Target | Patient Safety Practice | Implementation Cost/Complex |
| 18 | Mortality associated with surgical procedures | Localizing specific surgeries and procedures to high volume centers | High (varies) |
| 17.1 | Ventilator-associated pneumonia | Semi-recumbent positioning | Low |
| 26.5 | Falls and fall injuries | Use of hip protectors | Low |
| 8 | Adverse drug events (ADEs) related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection) | Use of computer monitoring for potential ADEs | Medium |
| 20.3 | Surgical site infections | Use of supplemental perioperative oxygen | Low |
| 39 | Morbidity and mortality | Changes in nursing staffing | Medium |
| 48 | Missed or incomplete or not fully comprehended informed consent | Use of video or audio stimuli | Low |
| 17.3 | Ventilator-associated pneumonia | Selective decontamination of digestive tract | Low |
| 38 | Morbidity and mortality in ICU patients | Change in ICU structure—active management by intensivist | High |
| 42.1 | Adverse events related to discontinuities in care | Information transfer between inpatient and outpatient pharmacy | Medium |
| 15.1 | Hospital-acquired urinary tract infection | Use of silver alloy-coated catheters | Low |
| 28 | Hospital-related delirium | Multi-component delirium prevention program | Medium |
| 30 | Hospital-acquired complications (functional decline, mortality) | Geriatric evaluation and management unit | High |
| 37.4 | Inadequate postoperative pain management | Non-pharmacologic interventions (e.g., relaxation, distraction) | Low |
Table 57.3 Patient Safety Practices with Medium Strength of Evidence Regarding their Impact and Effectiveness
| Chapter | Patient Safety Target | Patient Safety Practice | Implementation Cost/Complex |
| 6 | Medication errors and adverse drug events (ADEs) primarily related to ordering process | Computerized physician order entry (CPOE) and clinical decision support (CDSS) | High |
| 42.4 | Failures to communicate significant abnormal results (e.g., pap smears) | Protocols for notification of test results to patients | Low |
| 47 | Adverse events due to transportation of critically ill patients between healthcare facilities | Specialized teams for interhospital transport | Medium |
| 7 | Medication errors and adverse drug events (ADEs) related to ordering and monitoring | Clinical pharmacist consultation services | Medium |
| 13 | Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile) | Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel) | Medium |
| 20.4 | Surgical site infections | Perioperative glucose control | Medium |
| 34 | Stress-related gastrointestinal bleeding | H2 antagonists | Low |
| 36 | Pneumococcal pneumonia | Methods to increase pneumococcal vaccination rate | Low |
| 37.2 | Inadequate pain relief | Acute pain service | Medium |
| 9 | Adverse events related to anticoagulation | Anticoagulation services and clinics for coumadin | Medium |
| 14 | Hospital-acquired infections due to antibiotic-resistant organisms | Limitations placed on antibiotic use | Low |
| 15.2 | Hospital-acquired urinary tract infection | Use of suprapubic catheters | High |
| 32 | Contrast-induced renal failure | Hydration protocols with acetylcysteine | Low |
| 35 | Clinically significant misread radiographs and CT scans by non-radiologists | Education interventions and continuous quality improvement strategies | Low |
| 48 | Missed or incomplete or not fully comprehended informed consent | Provision of written informed consent information | Low |
| 49 | Failure to honor patient preferences for end-of-life care | Computer-generated reminders to discuss advanced directives | Medium (Varies) |
| 9 | Adverse events related to anticoagulation | Protocols for high-risk drugs: nomograms for heparin | Low |
| 17.1 | Ventilator-associated pneumonia | Continuous oscillation | Medium |
| 20.2 | Surgical site infections | Maintenance of perioperative normothermia | Low |
| 26.2 | Restraint-related injury; Falls | Interventions to reduce the use of physical restraints safely | Medium |
| 26.3 | Falls | Use of bed alarms | Medium |
| 32 | Contrast-induced renal failure | Use of low osmolar contrast media | Medium |
Table 57.4 Patient Safety Practices with Lower Impact and/or Strength of Evidence
| Chapter | Patient Safety Target | Patient Safety Practice | Implementation Cost/Complex |
| 16.3 | Central venous catheter-related bloodstream infections | Cleaning site (povidone-iodine to chlorhexidine) | Low |
| 16.4 | Central venous catheter-related bloodstream infections | Use of heparin | Low |
| 16.4 | Central venous catheter-related bloodstream infections | Tunneling short-term central venous catheters | Medium |
| 29 | Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality) | Geriatric consultation services | High |
| 37.1 | Inadequate pain relief in patients with abdominal pain in hospital patients | Use of analgesics in the patient with acute abdomen without compromising diagnostic accuracy | Low |
| 45 | Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations | Simulator-based training | Medium |
| 11 | Adverse drug events (ADEs) in drug dispensing and/or administration | Use of automated medication dispensing devices | Medium |
| 12 | Hospital-acquired infections | Improve handwashing compliance (via education/behavior change; sink technology and placement; washing substance) | Low |
| 49 | Failure to honor patient preferences for end-of-life care | Use of physician order form for life-sustaining treatment (POLST) | Low |
| 43.1 | Adverse events due to patient misidentification | Use of bar coding | Medium (Varies) |
| 10 | Adverse drug events (ADEs) in dispensing medications | Unit-dosing distribution system | Low |
| 24 | Critical events in anesthesia | Intraoperative monitoring of vital signs and oxygenation | Low |
| 42.2 | Adverse events during cross-coverage | Standardized, structured sign-outs for physicians | Low |
| 44 | Adverse events related to team performance issues | Applications of aviation-style crew resource management (e.g., Anesthesia Crisis Management; MedTeams) | High |
| 46 | Adverse events related to fatigue in healthcare workers | Limiting individual provider's hours of service | High |
57.5 Patient Safety Practices with Lowest Impact and/or Strength of Evidence
| Chapter | Patient Safety Target | Patient Safety Practice | Implementation Cost/Complex |
| 23 | Complications due to anesthesia equipment failures | Use of pre-anesthesia checklists | Low |
| 42.3 | Adverse events related to information loss at discharge | Use of structured discharge summaries | Low |
| 22 | Surgical items left inside patients | Counting sharps, instruments and sponges | Low |
| 17.4 | Ventilator-associated pneumonia | Use of sucralfate | Low |
| 26.4 | Falls and fall-related injuries | Use of special flooring material in patient care areas | Medium |
| 43.2 | Performance of invasive diagnostic or therapeutic procedure on wrong body part | Protocols | Medium |
| 26.1 | Falls | Use of identification bracelets | Low |
| 32 | Contrast-induced renal failure | Hydration protocols with theophylline | Low |
| 47 | Adverse events due to transportation of critically ill patients within a hospital | Mechanical rather than manual ventilation during transport | Low |
| 16.4 | Central venous catheter-related bloodstream infections | Changing catheters routinely | High |
| 16.4 | Central venous catheter-related bloodstream infections | Routine antibiotic prophylaxis | Medium |