Chapter 4. Determining the Target Patient Safety Practices

Assessing the Evidence for Context-Sensitive Effectiveness and Safety

We selected five types of patient safety practices (PSPs) for the diverse and representative set of practices on which the rest of this project focused:

  1. Checklists for catheter-related bloodstream infection prevention.
  2. Universal Protocol for preventing wrong procedure, wrong site, wrong person surgery.
  3. Computerized physician order entry and decision support system.
  4. Medication reconciliation.
  5. Interventions to prevent in-facility falls.

We selected these five PSPs after conducting a series of activities, one of which was a survey of the TEP. The full results of that survey are found in Appendix B. Our definitions for the PSPs follow.

Universal Protocol

The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery was created by the Joint Commission and became effective in 2004.1 The protocol consists of three components: conducting a pre-procedure verification process, marking the procedure site, and a 'time out" session before starting the procedure. The protocol targets a very rare event but one that presumably is a preventable event.2 It was designed to address surgery errors with tragic consequences but has since been adopted in other fields or has been expanded to non-surgical fields.3 The Joint Commission recommends the use of a checklist but does not mandate it. Checklists seem to be a prominent way to implement the Universal Protocol and to ensure that its components actually take place.

Medication Reconciliation

Medication reconciliation is the practice of acquiring an accurate medication history at each transition in care.4 It aims to reduce adverse drug events that result because of medication information that is lost as patients transfer from one setting to another. Many different medication reconciliation interventions have been developed for use by health care providers, but most rely on two main components:

  1. Development of forms and procedures to capture information and compare for discrepancies from different sources (e.g., primary care, admission, discharge).
  2. Work flow and role assignment among providers (and sometimes patients).

In addition, interventions often include education of providers (and sometimes patients) on the new processes and paperwork (or electronic tools) and audit and feedback regarding compliance with the process and the benefits of reconciliation.

Computerized Physician Order Entry (CPOE) and Decision Support Systems (DSS)

CPOE can be thought of as direct entry of medical orders into the computer. DSS has been described as "a wide range of computerized tools directed at improving patient care, including computerized reminders and advice regarding drug selection, dosage, interactions, allergies, and the need for subsequent orders."5 However, DSS vary substantially in their features and capabilities.6 In this context, DSS refers to decision support regarding prescribing to help reduce adverse drug events (check for dosing errors, drug-drug interactions, etc.).

Fall Prevention Programs

Many different interventions have been developed to prevent falls, including multifactorial falls risk assessment and management, exercise, environmental modifications, education, and review of drugs, and programs that target risk factor reduction (identifying and reducing fall risk factors that can be removed or reduced). Risk factor reduction is one component in most programs (e.g. a clinical medication review by a pharmacist and treatment of care home residents). Most falls prevention interventions in institutions are a combination of components (multi-factorial) that may be prescribed for the implementers by label in a "bundle" (e.g., "implement an education program for staff and residents, risk assessment, non-slip mats, and medications review—how you do this is up to you") or not prescribed for the implementers, instead it is a "menu" of labels and examples from which implementers choose.

Blood Stream Infection Prevention Efforts

A large variety of patient safety interventions have been evaluated for reducing central line-associated bloodstream infections (CLABSI).7 Most are technical, such as avoiding the femoral insertion site and use of specific skin disinfection solutions. However, more recently, a few studies have been oriented towards quality improvement and human factors issues, including elements such as staff education, infection control programs, and feedback. We defined the patient safety practice for catheter-related infection or CLABSI prevention as practices, policies, or checklists to reduce the rate of infections acquired as a result of placement and maintenance of intravascular catheters in hospitalized patients.

References for Chapter 4

  1. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Washington, DC: The Joint Commission; 2009. Available at Accessed March 2010.
  2. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006; 141:3537.
  3. Angle JF, Nemcek AA, Cohen AM, et al. Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: Application of The Joint Commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" to the practice of interventional radiology. J Vasc Interv Radiol 2008; 19(8):1145-51.
  4. AHRQ Patient Safety Network—Glossary. Available at Accessed September 30, 2010.
  5. Wolfstadt JI, Gurwitz JH, Field TS, et al. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: A systematic review. J Gen Intern Med 2008; 23(4):451-8.
  6. Wright A, Sittig DF, Ash JS, et al. Clinical decision support capabilities of commercially available clinical information systems. JAMIA 2009 16(5):637-44.
  7. Ramritu P, Halton K, Cook D, et al. Catheter-related bloodstream infections in intensive care units: A systematic review with meta-analysis. J Adv Nurs 2008; 62(1):3-21.
Current as of December 2010
Internet Citation: Chapter 4. Determining the Target Patient Safety Practices: Assessing the Evidence for Context-Sensitive Effectiveness and Safety . December 2010. Agency for Healthcare Research and Quality, Rockville, MD.