Ch. # |
Patient Safety Target |
Patient Safety Practice |
Impact |
Study Strength |
Effect Size |
Vigilance |
Cost |
Complexity |
6 |
Medication errors and adverse drug events (ADEs) primarily related to
ordering process |
Computerized physician order entry (CPOE) with clinical decision
support system (CDSS) |
High |
Medium1 |
Modest |
Medium |
High2 |
High |
7 |
Medication errors and ADEs related to ordering and monitoring
|
Clinical pharmacist consultation services |
High |
Medium |
Modest3 |
Low |
High |
Low |
8 |
ADEs related to targeted classes (analgesics, KCl, antibiotics,
heparin) (focus on detection) |
Use of computer monitoring for potential ADEs |
Medium |
Medium |
Robust4 |
Low |
Medium5 |
Low |
9 |
Adverse events related to anticoagulation |
Protocols for high risk drugs: nomograms for heparin |
Medium |
Medium6 |
Robust7 |
Medium |
Low |
Low |
9 |
Adverse events related to anticoagulation |
Anticoagulation services and clinics for coumadin8 |
High |
Medium |
Unclear |
Low |
Medium |
Low |
9 |
Adverse events related to chronic anticoagulation with warfarin
|
Patient self-management using home monitoring devices |
High |
High |
Robust |
Medium |
Medium9 |
High10 |
10 |
ADEs in dispensing medications |
Unit-dosing distribution system |
Medium11 |
Medium |
Unclear |
Low |
Low |
Low |
11 |
ADEs in drug dispensing and/or administration |
Use of automated medication dispensing devices |
High |
Medium12 |
Unclear |
Medium |
Medium13 |
Low |
12 |
Hospital-acquired infections |
Improved handwashing compliance (via education/behavior change; sink
technology and placement; washing substance) |
High |
Medium14 |
Unclear15 |
Low |
Low |
Low16 |
13 |
Serious nosocomial infections (e.g., vancomycin-resistant enterococcus,
C. difficile) |
Barrier precautions (via gowns & gloves; dedicated equipment;
dedicated personnel) |
High |
Medium17 |
Robust |
Medium18 |
Medium |
Low19 |
14 |
Hospital-acquired infections due to antibiotic-resistant organisms
|
Limitations placed on antibiotic use |
High20 |
Medium |
Modest |
Medium21 |
Low |
Low |
15.1 |
Hospital-acquired urinary tract infection |
Use of silver alloy-coated catheters |
High |
High |
Unclear22 |
Low |
Low |
Low |
15.2 |
Hospital-acquired urinary tract infection |
Use of suprapubic catheters |
High |
High |
Unclear23 |
Medium |
High |
High |
16.1 |
Central venous catheter-related blood infections |
Use of maximum sterile barriers during catheter insertion
|
Medium |
High |
Robust |
Low |
Low |
Low24 |
16.2 |
Central venous catheter-related blood infections |
Antibiotic-impregnated catheters |
Medium |
High |
Robust |
Low25 |
Low |
Low |
16.3 |
Central venous catheter-related blood infections |
Cleaning site (povidone-iodine to chlorhexidine) |
Medium |
High |
Unclear |
Low |
Low |
Low |
16.4 |
Central venous catheter-related blood infections |
Changing catheters routinely |
Medium |
High |
Negligible± |
NA |
High |
High |
16.4 |
Central venous catheter-related blood infections |
Use of heparin |
Medium |
High |
Unclear |
Medium |
Low |
Low |
16.4 |
Central venous catheter-related blood infections |
Tunneling short-term central venous catheters |
Medium |
High |
Unclear |
Low |
Low |
High |
16.4 |
Central venous catheter-related blood infections |
Routine antibiotic prophylaxis |
Medium |
Medium |
Negligible |
Medium |
Medium |
Low |
17.1 |
Ventilator-associated pneumonia |
Semi-recumbent positioning |
High |
Medium |
Robust26 |
Low |
Low |
Low |
17.1 |
Ventilator-associated pneumonia |
Continuous oscillation |
High |
High |
Robust27 |
Medium |
Medium |
Low |
17.2 |
Ventilator-associated pneumonia |
Continuous aspiration of subglottic secretions (CASS) |
High |
High |
Robust28 |
Low |
Low |
High29 |
17.3 |
Ventilator-associated pneumonia |
Selective decontamination of digestive tract |
High |
High |
Robust30 |
Medium31 |
Low |
Low |
17.4 |
Ventilator-associated pneumonia |
Sucralfate |
High |
High |
Unclear |
High32 |
Low |
Low |
18 |
Mortality associated with surgical procedures |
Localizing specific surgeries and procedures to high volume centers
|
High |
Medium33 |
Varies |
Medium |
Varies |
High |
20.1 |
Surgical site infections |
Appropriate use of antibiotic prophylaxis |
Medium34 |
High |
Robust |
Medium35 |
Low |
Low |
20.2 |
Surgical site infections |
Maintenance of perioperative normothermia |
High |
Medium36 |
Robust |
Medium37 |
Low |
Low |
20.3 |
Surgical site infections |
Use of supplemental perioperative oxygen |
High |
Medium38 |
Robust |
Low |
Low |
Low |
20.4 |
Surgical site infections |
Perioperative glucose control |
High |
Medium |
Robust |
Medium |
Low |
High39 |
21 |
Morbidity due to central venous catheter insertion |
Use of real-time ultrasound guidance during central line insertion
|
High |
High |
Robust40 |
Low41 |
Medium |
High |
22 |
Surgical items left inside patient |
Counting sharps, instruments, sponges |
Insuff. Info.42 |
Low |
Not rated |
Not rated |
Low |
Low |
23 |
Complications due to anesthesia equipment failures |
Use of preoperative anesthesia checklists |
Low43 |
Low |
Not rated |
Not rated |
Low |
Low |
24 |
Critical events in anesthesia |
Intraoperative monitoring of vital signs and oxygenation |
Low44 |
Medium45 |
Unclear46 |
Low |
Low |
Low |
25 |
Perioperative cardiac events in patients undergoing noncardiac surgery
|
Use of perioperative beta-blockers |
High |
High |
Robust |
Medium |
Low |
Low |
26.1 |
Falls |
Use of identification bracelets |
Medium |
Medium |
Negligible |
Low |
Low |
Low |
26.2 |
Restraint-related injuries; Falls |
Interventions to reduce the use of physical restraints safely
|
Medium |
Medium |
Unclear47 |
Medium |
Medium |
Low |
26.3 |
Falls |
Use of bed alarms |
Medium |
Medium |
Unclear |
Low48 |
Medium49 |
Low |
26.4 |
Falls and fall-related injuries |
Use of special flooring material in patient care areas |
Medium |
Low |
Not rated |
Not rated |
High |
Low |
26.5 |
Falls and fall injuries |
Use of hip protectors |
Medium |
High |
Robust |
Medium |
Low50 |
Low51 |
27 |
Pressure ulcers |
Use of pressure relieving bedding materials |
High |
High |
Robust52 |
Low |
High |
Low |
28 |
Hospital-related delirium |
Multi-component delirium prevention program |
High |
Medium |
Robust |
Low |
Medium |
Low |
29 |
Hospital-acquired complications (e.g., falls, delirium, functional
decline, mortality) |
Geriatric consultation services |
High |
High |
Varies53 |
Low |
Medium |
High |
± Actually, studies show a detrimental effect of practice.