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Chapter 59. Listing of All Practices, Categorical Ratings, and Comments

Ch. #Patient Safety TargetPatient Safety PracticeImpactStudy StrengthEffect SizeVigilanceCostComplexity
6Medication errors and adverse drug events (ADEs) primarily related to ordering processComputerized physician order entry (CPOE) with clinical decision support system (CDSS)HighMedium1ModestMediumHigh2High
7Medication errors and ADEs related to ordering and monitoringClinical pharmacist consultation servicesHighMediumModest3LowHighLow
8ADEs related to targeted classes (analgesics, KCl, antibiotics, heparin) (focus on detection)Use of computer monitoring for potential ADEsMediumMediumRobust4LowMedium5Low
9Adverse events related to anticoagulationProtocols for high risk drugs: nomograms for heparinMediumMedium6Robust7MediumLowLow
9Adverse events related to anticoagulationAnticoagulation services and clinics for coumadin8HighMediumUnclearLowMediumLow
9Adverse events related to chronic anticoagulation with warfarinPatient self-management using home monitoring devicesHighHighRobustMediumMedium9High10
10ADEs in dispensing medicationsUnit-dosing distribution systemMedium11MediumUnclearLowLowLow
11ADEs in drug dispensing and/or administrationUse of automated medication dispensing devicesHighMedium12UnclearMediumMedium13Low
12Hospital-acquired infectionsImproved handwashing compliance (via education/behavior change; sink technology and placement; washing substance)HighMedium14Unclear15LowLowLow16
13Serious nosocomial infections (e.g., vancomycin-resistant enterococcus, C. difficile)Barrier precautions (via gowns & gloves; dedicated equipment; dedicated personnel)HighMedium17RobustMedium18MediumLow19
14Hospital-acquired infections due to antibiotic-resistant organismsLimitations placed on antibiotic useHigh20MediumModestMedium21LowLow
15.1Hospital-acquired urinary tract infectionUse of silver alloy-coated cathetersHighHighUnclear22LowLowLow
15.2Hospital-acquired urinary tract infectionUse of suprapubic cathetersHighHighUnclear23MediumHighHigh
16.1Central venous catheter-related blood infectionsUse of maximum sterile barriers during catheter insertionMediumHighRobustLowLowLow24
16.2Central venous catheter-related blood infectionsAntibiotic-impregnated cathetersMediumHighRobustLow25LowLow
16.3Central venous catheter-related blood infectionsCleaning site (povidone-iodine to chlorhexidine)MediumHighUnclearLowLowLow
16.4Central venous catheter-related blood infectionsChanging catheters routinelyMediumHighNegligible±NAHighHigh
16.4Central venous catheter-related blood infectionsUse of heparinMediumHighUnclearMediumLowLow
16.4Central venous catheter-related blood infectionsTunneling short-term central venous cathetersMediumHighUnclearLowLowHigh
16.4Central venous catheter-related blood infectionsRoutine antibiotic prophylaxisMediumMediumNegligibleMediumMediumLow
17.1Ventilator-associated pneumoniaSemi-recumbent positioningHighMediumRobust26LowLowLow
17.1Ventilator-associated pneumoniaContinuous oscillationHighHighRobust27MediumMediumLow
17.2Ventilator-associated pneumoniaContinuous aspiration of subglottic secretions (CASS)HighHighRobust28LowLowHigh29
17.3Ventilator-associated pneumoniaSelective decontamination of digestive tractHighHighRobust30Medium31LowLow
17.4Ventilator-associated pneumoniaSucralfateHighHighUnclearHigh32LowLow
18Mortality associated with surgical proceduresLocalizing specific surgeries and procedures to high volume centersHighMedium33VariesMediumVariesHigh
20.1Surgical site infectionsAppropriate use of antibiotic prophylaxisMedium34HighRobustMedium35LowLow
20.2Surgical site infectionsMaintenance of perioperative normothermiaHighMedium36RobustMedium37LowLow
20.3Surgical site infectionsUse of supplemental perioperative oxygenHighMedium38RobustLowLowLow
20.4Surgical site infectionsPerioperative glucose controlHighMediumRobustMediumLowHigh39
21Morbidity due to central venous catheter insertionUse of real-time ultrasound guidance during central line insertionHighHighRobust40Low41MediumHigh
22Surgical items left inside patientCounting sharps, instruments, spongesInsuff. Info.42LowNot ratedNot ratedLowLow
23Complications due to anesthesia equipment failuresUse of preoperative anesthesia checklistsLow43LowNot ratedNot ratedLowLow
24Critical events in anesthesiaIntraoperative monitoring of vital signs and oxygenationLow44Medium45Unclear46LowLowLow
25Perioperative cardiac events in patients undergoing noncardiac surgeryUse of perioperative beta-blockersHighHighRobustMediumLowLow
26.1FallsUse of identification braceletsMediumMediumNegligibleLowLowLow
26.2Restraint-related injuries; FallsInterventions to reduce the use of physical restraints safelyMediumMediumUnclear47MediumMediumLow
26.3FallsUse of bed alarmsMediumMediumUnclearLow48Medium49Low
26.4Falls and fall-related injuriesUse of special flooring material in patient care areasMediumLowNot ratedNot ratedHighLow
26.5Falls and fall injuriesUse of hip protectorsMediumHighRobustMediumLow50Low51
27Pressure ulcersUse of pressure relieving bedding materialsHighHighRobust52LowHighLow
28Hospital-related deliriumMulti-component delirium prevention programHighMediumRobustLowMediumLow
29Hospital-acquired complications (e.g., falls, delirium, functional decline, mortality)Geriatric consultation servicesHighHighVaries53LowMediumHigh

± Actually, studies show a detrimental effect of practice.

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Current as of July 2001
Internet Citation: Chapter 59. Listing of All Practices, Categorical Ratings, and Comments. July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/chapter59a.html