Making Health Care Safer II

An Updated Critical Analysis of the Evidence for Patient Safety Practices

This evidence report updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

For a list of 22 patient safety strategies discussed in the new report that are ready for adoption, and for information on an Annals of Internal Medicine supplement featuring 10 articles on selected patient safety strategies from the report, go to www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html.

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Structured Abstract

Objectives: To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

Data sources: Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.

Review methods: The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains:

  • How important is the problem?
  • What is the patient safety practice?
  • Why should this practice work?
  • What are the beneficial effects of the practice?
  • What are the harms of the practice?
  • How has the practice been implemented, and in what contexts?
  • Are there any data about costs?
  • Are there data about the effect of context on effectiveness?

We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption.

Results: From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption.

Conclusions: The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.


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Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices

  • Executive Summary (Publication No. 13-E001-1-EF).
  • Evidence Report (Publication No. 13-E001-EF)
    • Full Report (PDF file PDF File, 10 MB).
    • Chapter 1. Introduction (PDF file PDF File, 30 KB).
    • Chapter 2. Methods (PDF file PDF File, 460 KB).
    • Chapter 3. High-Alert Drugs: Patient Safety Practices for Intravenous Anticoagulants (PDF file PDF File, 60 KB).
    • Chapter 4. Clinical Pharmacist’s Role in Preventing Adverse Drug Events (PDF file PDF File, 65 KB).
    • Chapter 5. The Joint Commission’s "Do Not Use" List (PDF file PDF File, 150 KB).
    • Chapter 6. Smart Pumps and Other Protocols for Infusion Pumps (PDF file PDF File, 55 KB).
    • Chapter 7. Barrier Precautions, Patient Isolation, and Routine Surveillance for Prevention of Healthcare-Associated Infections (PDF file PDF File, 80 KB).
    • Chapter 8. Interventions To Improve Hand Hygiene Compliance (PDF file PDF File, 40 KB).
    • Chapter 9. Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections (PDF file PDF File, 290 KB).
    • Chapter 10. Prevention of Central Line-Associated Bloodstream Infections (PDF file PDF File, 210 KB).
    • Chapter 11. Ventilator-Associated Pneumonia (PDF file PDF File, 50 KB).
    • Chapter 12. Interventions To Allow the Reuse of Single-Use Devices (PDF file PDF File, 45 KB).
    • Chapter 13. Preoperative and Anesthesia Checklists (PDF file PDF File, 245 KB).
    • Chapter 14. Use of Report Cards and Outcome Measurements To Improve Safety of Surgical Care (PDF file PDF File, 375 KB).
    • Chapter 15. Prevention of Surgical Items Being Left Inside Patient (PDF file PDF File, 40 KB).
    • Chapter 16. Operating Room Integration and Display Systems (PDF file PDF File, 50 KB).
    • Chapter 17. Use of Beta Blockers To Prevent Perioperative Cardiac Events (PDF file PDF File, 25 KB).
    • Chapter 18. Use of Real-Time Ultrasound Guidance During Central Line Insertion (PDF file PDF File, 45 KB).
    • Chapter 19. Preventing In-Facility Falls (PDF file PDF File, 500 KB).
    • Chapter 20. Preventing In-Facility Delirium (PDF file PDF version - 138 KB ).
    • Chapter 21. Preventing In-Facility Pressure Ulcers (PDF file PDF File, 155 KB).
    • Chapter 22. Inpatient Intensive Glucose Control Strategies To Reduce Death and Infection (PDF file PDF File, 535 KB).
    • Chapter 23. Interventions To Prevent Contrast-Induced Acute Kidney Injury (PDF file PDF File, 70 KB).
    • Chapter 24. Rapid Response Systems (PDF file PDF File, 100 KB).
    • Chapter 25. Medication Reconciliation Supported by Clinical Pharmacists (PDF file PDF File, 445 KB).
    • Chapter 26. Identifying Patients at Risk for Suicide (PDF file PDF File, 70 KB).
    • Chapter 27. Strategies To Prevent Stress-Related Gastrointestinal Bleeding (Stress Ulcer Prophylaxis) (PDF file PDF File, 100 KB).
    • Chapter 28. Prevention of Venous Thromboembolism (PDF file PDF File, 50 KB).
    • Chapter 29. Preventing Patient Death or Serious Injury Associated With Radiation Exposure From Fluoroscopy and Computed Tomography (PDF file PDF File, 100 KB).
    • Chapter 30. Ensuring Documentation of Patients’ Preferences for Life-Sustaining Treatment (PDF file PDF File, 40 KB).
    • Chapter 31. Human Factors and Ergonomics (PDF file PDF File, 275 MB).
    • Chapter 32. Promoting Engagement by Patients and Families To Reduce Adverse Events (PDF file PDF File, 75 KB).
    • Chapter 33. Promoting Culture of Safety (PDF file PDF File, 70 KB).
    • Chapter 34. Effect of Nurse-to-Patient Staffing Ratios on Patient Morbidity and Mortality (PDF file PDF File, 780 KB).
    • Chapter 35. Patient Safety Practices Targeted at Diagnostic Errors (PDF file PDF File, 225 KB).
    • Chapter 36. Monitoring Patient Safety Problems (PDF file PDF File, 170 KB).
    • Chapter 37. Interventions to Improve Care Transitions at Hospital Discharge (PDF file PDF File, 100 KB).
    • Chapter 38. Use of Simulation Exercises in Patient Safety Efforts (PDF file PDF File, 140 KB).
    • Chapter 39. Obtaining Informed Consent From Patients (PDF file PDF File, 88 KB).
    • Chapter 40. Team-Training in Health Care (PDF file PDF File, 90 KB).
    • Chapter 41. Computerized Provider Order Entry With Clinical Decision Support Systems (PDF file PDF File, 60 KB).
    • Chapter 42. Tubing Misconnections (PDF file PDF File, 50 KB).
    • Chapter 43. Limiting Individual Provider's Hours of Service (PDF file PDF File, 50 KB).
    • Chapter 44. Discussion (PDF file PDF File, 125 KB).
    • Appendix A (PDF file PDF File, 35 KB).
    • Appendix B (PDF file PDF File, 75 KB).
    • Appendix C (PDF file PDF File, 1.7 MB).
    • Appendix D (PDF file PDF File, 2 MB).
  • Original Evidence Report (Publication No. 01-E058, July 2001).

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Evidence-based Practice Centers: RAND Corporation; University of California, San Francisco/Stanford; Johns Hopkins University; ECRI Institute.

Page last reviewed March 2013
Internet Citation: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html