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

Chapter #	Patient Safety Target	Patient Safety Practice	Impact	Study Strength	Effect Size	Vigilance	Cost	Complexity
30	Hospital-acquired complications (functional decline, mortality)	Geriatric evaluation and management unit	High	High	Modest⁵⁴	Low	Medium	High
31	Venous thromboembolism (VTE)	Appropriate VTE prophylaxis	High	High	Robust	Medium	Low	Low⁵⁵
32	Contrast-induced renal failure	Use of low osmolar contrast media	Medium	High	Robust	Low	High⁵⁶	Low
32	Contrast-induced renal failure	Hydration protocols with theophylline	Medium	High	Negligible	Low	Low	Low
32	Contrast-induced renal failure	Hydration protocols with acetylcysteine	Medium	Medium⁵⁷	Robust	Low	Low	Low
33	Morbidity and mortality in post-surgical and critically ill patients	Various nutritional strategies	High	High	Robust⁵⁸	Medium	Medium	Low
34	Stress-related gastrointestinal bleeding	H₂-antagonists	Medium	High	Unclear	Medium⁵⁹	Low	Low
35	Clinically significant misread radiographs and CT scans by non-radiologists	Education interventions and continuous quality improvement strategies	Medium	Medium	Robust	Low	Low	Low
36	Pneumococcal pneumonia	Methods to increase pneumococcal vaccination rate	Medium	High	Unclear⁶⁰	Low ⁶¹	Low	Low
37.1	Inadequate pain relief in hospital patients with abdominal pain	Use of analgesics in patients with acute abdomen without compromising diagnostic accuracy	High	Medium⁶²	Robust	Medium	Low	Low⁶³
37.2	Inadequate pain relief	Acute pain service	High	Medium	Robust⁶⁴	Low⁶⁵	Medium	Low
37.4	Inadequate postoperative pain management	Non-pharmacologic interventions (e.g., relaxation, distraction)	High	High	Unclear	Low	Low	Low
38	Morbidity and mortality in ICU patients	Change in ICU structure—active management by intensivist	High	Medium	Robust⁶⁶	Low	Medium	High
39	Morbidity and mortality	Changes in nursing staffing	High	Medium⁶⁷	Varies	Low	High	Low⁶⁸
40	Any safety problem amenable to culture	Promoting a culture of safety	Insuff. Info.	**⁶⁹			Varies	High
41.1	Medical device related adverse events	Use of human factors principles in evaluation of medical devices	Insuff. Info.	**⁷⁰			Varies	High
41.2	Adverse events	Refining performance of medical device alarms (e.g., balancing sensitivity and specificity of alarms, ergonomic design)	High⁷¹	**⁷²			Varies	High
42.1	Adverse events related to discontinuities in care	Information transfer between inpatient and outpatient pharmacy	High	Medium	Robust	Low	Medium⁷³	Low
42.2	Adverse events during cross-coverage	Standardized, structured sign-outs for physicians	Medium	Low	Not rated	Not rated	Low⁷⁴	Low
42.3	Adverse events related to information loss at discharge	Use of structured discharge summaries	Insuff. Info	Low⁷⁵	Not rated	Not rated	Low	Low
42.4	Failures to communicate significant abnormal results (e.g., pap smears)	Protocols for notification of test results to patients	Medium	Medium	Modest	Low	Low	Low
43.1	Adverse events due to patient misidentification	Use of bar coding	High⁷⁶	Low	Not rated	Not rated	Varies⁷⁷	High
43.2	Performance of invasive diagnostic or therapeutic procedure on wrong body part	"Sign your site" protocols	High	Low	Not rated	Not rated	Low	High
44	Adverse events related to team performance issues	Application of aviation style crew resource management (e.g., Anesthesia Crisis Management; MedTeams)	High⁷⁸	Low	Not rated	Not rated	Medium	High
45	Adverse events due to provider inexperience or unfamiliarity with certain procedures and situations	Simulator-based training	Insuff. Info⁷⁹	Medium⁸⁰	Unclear⁸¹	Low	Medium	Low
46	Adverse events related to fatigue in healthcare workers	Limiting individual provider's hours of service	Insuff. Info.	Medium	Unclear	Low	High	High
46	Adverse events related to fatigue in healthcare workers	Fixed shifts or forward shift rotations	Insuff. Info.	**⁸²			Varies⁸³	Varies⁷³
46	Adverse events related to fatigue in healthcare workers	Napping strategies	Insuff. Info.	**⁸⁴			High⁸⁵	Low
47	Adverse events due to transportation of critically ill patients between healthcare facilities	Specialized teams for interhospital transport	Medium	Medium⁸⁶	Modest	Low	Medium	Low
47	Adverse events due to transportation of critically ill patients within a hospital	Mechanical ventilation	Medium	Medium	Negligible	Low	Low	Low
48	Missed, incomplete or not fully comprehended informed consent	Asking that patients recall and restate what they have been told during informed consent	High	Medium	Robust	Low	Low	Low⁸⁷
48	Missed, incomplete or not fully comprehended informed consent	Use of video or audio stimuli	High	Medium	Modest	Low	Low⁸⁸	Low
48	Missed, incomplete or not fully comprehended informed consent	Provision of written informed consent information	High	Medium	Unclear	Low	Low	Low
49	Failure to honor patient preferences for end-of-life care	Computer-generated reminders to discuss advanced directives	High	Medium	Robust	Low	Medium⁸⁹	Low
49	Failure to honor patient preferences for end-of-life care	Use of physician order form for life-sustaining treatment (POLST)	High	Low	Not rated	Not rated	Low	Low⁹⁰

± Actually, studies show a detrimental effect of practice.

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Page last reviewed July 2001

Internet Citation: Chapter 59. Listing of All Practices, Categorical Ratings, and Comments (continued). July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/chapter59b.html