Addendum to Summary: Patient Safety Practices Rated by Strength of Evidence

After rating practices in terms of their potential impact, and on the strength of the evidence, the Editorial Board grouped them into 5 categories (Tables A-1 through A-5, adapted from Tables 57.1-57.5 of Making Health Care Safer: A Critical Analysis of Patient Safety Practices). These categorizations reflect the current state of the evidence. If a practice that addresses a very common or severe patient safety problem receives a low rating on the impact/evidence scale, it may be because the strength of the evidence base is still weak because there have been few evaluations. As a result the practice is likely to show up at a high level on the research priority scale. However, if the practice has been studied rigorously, and there is clear evidence that its effectiveness is negligible, it is rated at the low ends of both the "strength of the evidence" (on impact/effectiveness) scale and the "research priority" scale.

For each practice listed in the Tables, a designation for the cost and complexity of implementation of the practice is included. The ratings for implementation are "Low," which corresponds to low cost and low complexity of implementation (e.g., political or technical issues); "Medium," which represents low to medium cost and high complexity, or medium to high cost and low complexity; and "High," which reflects medium to high cost and high complexity of implementation.

Several practices are not included in the tables because they were not rated. Among these are a set of practices that have long histories of use outside of medicine, but have not yet received adequate evaluation of their potential health care applications:

• Promoting a Culture of Safety (Chapter 40).
• Use of Human Factors Principles in Evaluation of Medical Devices (Subchapter 41.1).
• Refining Performance of Medical Device Alarms (e.g., balancing sensitivity and specificity of alarms, ergonomic design) (Subchapter 41.2).
• Fixed Shifts or Forward Shift Rotations of health care personnel (Chapter 46).
• Napping Strategies for health care personnel (Chapter 46).
• Incident Reporting (Chapter 4).

Table A-1. Patient Safety Practices with the Greatest Strength of Evidence Regarding their Impact and Effectiveness *

Select for Table Version.

Item:1
Patient Safety Problem: Venous thromboembolism (VTE)
Patient Safety Practice: Appropriate VTE prophylaxis (Ch.31)*
Implementation Cost/Complexity: Low

Item:2
Patient Safety Problem: Perioperative cardiac events in patients undergoing noncardiac surgery
Patient Safety Practice: Use of perioperative beta-blockers (Ch.25)
Implementation Cost/Complexity: Low

Item:3
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Use of maximum sterile barriers during catheter insertion (Ch. 16.1)
Implementation Cost/Complexity: Low

Item:4
Patient Safety Problem: Surgical site infections
Patient Safety Practice: Appropriate use of antibiotic prophylaxis (Ch. 20.1)
Implementation Cost/Complexity: Low

Item:5
Patient Safety Problem: Missed, incomplete or not fully comprehended informed consent
Patient Safety Practice: Asking that patients recall and restate what they have been told during informed consent (Ch. 48)
Implementation Cost/Complexity: Low

Item:6
Patient Safety Problem: Ventilator-associated pneumonia
Patient Safety Practice: Continuous aspiration of subglottic secretions (CASS) (Ch. 17.2)
Implementation Cost/Complexity: Medium

Item:7
Patient Safety Problem: Pressure ulcers
Patient Safety Practice: Use of pressure relieving bedding materials (Ch.27)
Implementation Cost/Complexity: Medium

Item:8
Patient Safety Problem: Morbidity due to central venous catheter insertion
Patient Safety Practice: Use of real-time ultrasound guidance during central ine insertion (Ch.21)
Implementation Cost/Complexity: High

Item:9
Patient Safety Problem: Adverse events related to chronic anticoagulation with warfarin
Patient Safety Practice: Patient self management using home monitoring devices (Ch. 9)
Implementation Cost/Complexity: High

Item:10
Patient Safety Problem: Morbidity and mortality in post-surgical and critically ill patients
Patient Safety Practice: Various nutritional strategies (Ch.33)
Implementation Cost/Complexity: Medium

Item:11
Patient Safety Problem: Central venous catheter-related bloodstream infections
Patient Safety Practice: Antibiotic-impregnated catheters (Ch. 16.2)
Implementation Cost/Complexity: Low

Abbreviations: Ch. = Chapter
*Items within a particular category are not necessarily in rank order. Items are for reference only.

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Proceed to Table A-2