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

Chapter #	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.

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Page last reviewed July 2001

Internet Citation: Chapter 59. Listing of All Practices, Categorical Ratings, and Comments. July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/chapter59a.html