Making Health Care Safer II

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
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
Moderate Little/Not difficult
Strategies to increase appropriate prophylaxis for venous thromboembolism; brief review Common/Moderate High Moderate
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
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").


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.

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Page last reviewed March 2013
Page originally created March 2013
Internet Citation: Making Health Care Safer II. Content last reviewed March 2013. Agency for Healthcare Research and Quality, Rockville, MD.