Making health care safer: a critical analysis of patient safety practices

Agency for Healthcare Research and Quality (AHRQ)
Record ID 32001000981
Authors' objectives:

Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aims to collect and critically review the existing evidence on practices relevant to improving patient safety.

Authors' results and conclusions: Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. - Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk. - Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality. - Use of maximum sterile barriers while placing central intravenous catheters to prevent infections. - Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections. - Asking that patients recall and restate what they have been told during the informed consent process. - Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia. - Use of pressure relieving bedding materials to prevent pressure ulcers. - Use of real-time ultrasound guidance during central line insertion to prevent complications. - Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications. - Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients. - Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.
Authors' recommendations: An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.
Authors' methods: Systematic review
Project Status: Completed
Year Published: 2001
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: United States
MeSH Terms
  • Diagnostic Errors
  • Medical Errors
  • Medication Errors
  • Observer Variation
  • Safety Management
  • Patient Care
Organisation Name: Agency for Healthcare Research and Quality
Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;
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Copyright: Agency for Healthcare Research and Quality (AHRQ)
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.