An Updated Critical Analysis of the Evidence for Patient Safety Practices
Table B. Summary table*
| Patient Safety Practice | Scope of the Problem Targeted by the PSP (Frequency/ Severity) |
Strength of Evidence for Effectiveness of the PSPs | Evidence or Potential for Harmful Unintended Consequences | Estimate of Cost | Implementation Issues: How Much Do We Know?/How Hard Is it? |
|---|---|---|---|---|---|
| Practices Designed for a Specific Patient Safety Target | |||||
| Adverse Drug Events | |||||
| High-alert drugs: patient safety practices for intravenous anticoagulants; in-depth review | Common/Moderate | Low | Low-to-moderate | Low | Little/Moderate |
| Use of clinical pharmacists to prevent adverse drug events; brief review | Common/Low | Moderate-to-high | Low | High | Little/Moderate |
| The Joint Commission's "Do Not Use" list; brief review | Common/Low | Low | Negligible | Low | Little/Probably not difficult |
| Smart infusion pumps; brief review | Common/Low | Low | Low | Moderate | Moderate/Moderate |
| Infection Control | |||||
| Barrier precautions, patient isolation, and routine surveillance for the prevention of healthcare-associated infections; brief review | Common/Moderate | Moderate | Moderate (isolation of patients) |
Moderate-to-high | Moderate/Moderate |
| Interventions to improve hand hygiene compliance; brief review | Common/Moderate | Low | Low | Low | Moderate/Moderate |
| Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infections; brief review | Common/Moderate | Moderate-to-high | Low | Low | Moderate/Moderate |
| Prevention of central line-associated bloodstream infections; brief review | Common/Moderate | Moderate-to-high | Low | Low-to-moderate | Moderate-to-difficult/ Not difficult (implementation of a "bundle")-to-moderate (understanding organization culture and context) |
| Ventilator-associated pneumonia; brief review | Common/High | Moderate-to-high | Low | Low-to-moderate | Moderate/Moderate |
| Interventions to allow the reuse of single use devices; brief review | Common/Low | Low | Low | Low | A lot/Not difficult |
| Surgery, Anesthesia, and Perioperative Medicine | |||||
| Preoperative checklists and anesthesia checklists to prevent a number of operative safety events, such as surgical site infections and wrong site surgeries; in-depth review | Common/Moderate | High | Negligible | Low | A lot/Moderate |
| The use of ACS-NSQIP report cards and outcome measurements to decrease perioperative morbidity and mortality; in-depth review | Common/High | Moderate-to-high | Low | Moderate | Moderate/Moderate |
| New interventions to prevent surgical items from being left inside a patient; brief review | Rare/Low | Low | Negligible | Low if it simply involves more frequent manual counting; high if RFID is used | Little |
| Operating room integration and display systems, such as a centralized display of consolidated data; brief review | Common/Low-to-high | Low | Negligible | Moderate | Moderate/Moderate |
| Use of beta blockers to prevent perioperative cardiac events; brief review | Common/High | High evidence harms may equal or exceed benefits | High (death, stroke, hypotension, and bradycardia) |
Low | NA |
| Use of real-time ultrasound guidance during central line insertion to increase the proportion correctly placed on the first attempt; brief review | Common/Low-to-moderate | High | Negligible | Low-to-moderate | A lot/Moderate |
| Safety Practices for Hospitalized Elders | |||||
| Multicomponent interventions to prevent in-facility falls; in-depth review | Common/Low | High | Moderate (increased use of restraints and/or sedation) |
Moderate | Moderate/Moderate |
| Multicomponent interventions to prevent in-facility delirium; in-depth review | Common/Low | Moderate | Low | Moderate | Moderate/Moderate |
| General Clinical Topics | |||||
| Multicomponent initiatives to prevent pressure ulcers; in-depth review | Common/Moderate | Moderate | Negligible | Moderate | Moderate/Moderate |
| Inpatient, intensive, glucose control strategies to reduce death and infection; in-depth review | Common/Moderate | Moderate-to-high evidence it doesn't help | High (hypoglycemia) |
Low-to-moderate | NA |
| Interventions to prevent contrast-induced acute kidney injury; in-depth review | Common/Low | Low | Negligible | Low | Little/Not difficult |
| Rapid-response systems to prevent failure-to-rescue; in-depth review | Common/High | Moderate | Low | Moderate | Moderate/Moderate |
| Medication reconciliation supported by clinical pharmacists; in-depth review | Common/Low | Moderate | Low | Moderate | Moderate/Moderate |
| Identifying patients at risk for suicide; brief review | Rare/High | Low | Low | Moderate | Little/Moderate |
| Strategies to prevent stress-related gastrointestinal bleeding (stress ulcer prophylaxis); brief review | Rare/Moderate | Moderate | Moderate (pneumonia) |
Moderate | Little/Not difficult |
| Strategies to increase appropriate prophylaxis for venous thromboembolism; brief review | Common/Moderate | High | Moderate (bleeding) |
Low | Little/Moderate |
| Preventing patient death or serious injury associated with radiation exposure from fluoroscopy and computed tomography through technical interventions, appropriate utilization, and use of algorithms and protocols; brief review | Rare/High | Moderate | Negligible | Low | Moderate/Not difficult |
| Ensuring documentation of patient preferences for life-sustaining treatment, such as advanced directives; brief review | Common/Moderate | Moderate | Low | Low | Moderate/Moderate |
| Increasing nurse-to-patient staffing ratios to prevent death; in-depth review | Common/High | Moderate | Low | High | A lot/Not difficult |
| Practices Designed To Improve Overall System/Multiple Targets | |||||
| Increasing nurse-to-patient staff ratios to prevent falls, pressure ulcers, and other nursing sensitive outcomes (other than mortality); in-depth review | Common/High | Low | Low | High | A lot/Not difficult |
| Incorporation of human factors and ergonomics in the design of health care practices by hiring an expert or training clinicians in human factors; in-depth review | Potentially applicable to all patient safety problems | Not assessed systematically, but moderate-to-high evidence for some specific applications | Negligible | Moderate | A lot/Moderate |
| Promoting engagement by patients and families to reduce adverse events (such as patients encouraging providers to wash their hands); in-depth review | Common | Emerging practice (few studies available) | Uncertain | Low | Little/Moderate |
| Interventions to promote a culture of safety; in-depth review | Common/Low-to-high | Low | Uncertain | Low–to-moderate (varies) |
Moderate/Not difficult-to-moderate (varies with intervention) |
| Patient safety practices targeted at diagnostic errors; in-depth review | Common/High | Emerging practice (few studies available) |
Uncertain | Varies | Varies |
| Monitoring patient safety problems; in-depth review | Common/Low-to-high | Low | Negligible | High | Moderate/Difficult |
| Interventions to improve care transitions at hospital discharge; in-depth review | Common/Moderate | Low | Negligible | Moderate-to-high | Little/Difficult |
| Use of simulation-based training and exercises; in-depth review | Common/Moderate-to-high | Moderate-to-high for specific topics | Uncertain | Moderate | Moderate |
| Obtaining informed consent from patients to improve patient understanding of potential risks of medical procedures; brief review | Common/Moderate | Moderate | Negligible | Low | Moderate/Not difficult |
| Team-training in health care; brief review | Common/High | Moderate | Low | Moderate | Moderate/Moderate-to-difficult |
| Computerized provider order entry (CPOE) with clinical decision support systems (CDSS); brief review | Common/Moderate | Low-to-moderate | Low-to-moderate | High | Moderate/Difficult |
| Interventions to prevent tubing misconnections; brief review | Common/Moderate | Low | Low | Low | Moderate/Not difficult |
| Limiting trainee work hours; brief review | Common/Moderate | Low | Moderate (at least); includes lack of training time | High | Moderate/Difficult |
ACS NSQIP=American College of Surgeons National Surgical Quality Improvement Program; NA = not available; PSP = patient safety practice; RFID = radio-frequency identification.
*In some cases, the text in the "PSP" column differs slightly from the chapter heading for that PSP. This difference is attributable to our Technical Expert Panel's desire to include the target safety problem (if the practice is in fact targeted at a specific safety problem), more specification, or an example of the PSP (e.g., adding "such as a centralized display of consolidated data" to the PSP designated as "operating room integration and display systems").
Note:
Rating Scales:
Scope of the problem targeted by the PSP (frequency/severity): frequency = rare or common; severity = low, moderate, or high.
Strength of evidence for effectiveness of the PSPs: low, moderate, or high.
Evidence or potential for harmful unintended consequences: negligible, low, moderate, or high.
Estimate of cost: low, moderate, or high.
Implementation issues: How much do we know? = little, moderate, or a lot; How hard is it? = not difficult, moderate, or difficult.
