| PART I. Overview | ||
| 1. | An Introduction to the Compendium | |
| 1.1 | General Overview | |
| 1.2 | How to Use this Compendium | |
| 1.3 | Acknowledgments | |
| 2. | Drawing on Safety Practices from Outside Healthcare | |
| 3. | Evidence-Based Review Methodology | |
| PART II. Reporting and Responding to Patient Safety Problems | ||
| 4. | Incident Reporting | |
| 5. | Root Cause Analysis | |
| PART III. Patient Safety Practices & Targets | ||
| Section A. Adverse Drug Events (ADEs) | ||
| 6. | Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs) | |
| 7. | The Clinical Pharmacist’s Role in Preventing Adverse Drug Events | |
| 8. | Computer Adverse Drug Event (ADE) Detection and Alerts | |
| 9. | Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants | |
| 10. | Unit-Dose Drug Distribution Systems | |
| 11. | Automated Medication Dispensing Devices | |
| Section B. Infection Control | ||
| 12. | Practices to Improve Handwashing Compliance | |
| 13. | Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections | |
| 14. | Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance—Clostridium Difficile and Vancomycin-resistant Enterococcus (VRE) | |
| 15. | Prevention of Nosocomial Urinary Tract Infections | |
| 15.1 | Use of Silver Alloy Urinary Catheters | |
| 15.2 | Use of Suprapubic Catheters | |
| 16. | Prevention of Intravascular Catheter-Associated Infections | |
| 16.1 | Use of Maximum Barrier Precautions during Central Venous Catheter Insertion | |
| 16.2 | Use of Central Venous Catheters Coated with Antibacterial or Antiseptic Agents | |
| 16.3 | Use of Chlorhexidine Gluconate at the Central Venous Catheter Insertion Site | |
| 16.4 | Other Practices | |
| 17. | Prevention of Ventilator-Associated Pneumonia (VAP) | |
| 17.1 | Patient Positioning: Semi-recumbent Positioning and Continuous Oscillation | |
| 17.2 | Continuous Aspiration of Subglottic Secretions | |
| 17.3 | Selective Digestive Tract Decontamination | |
| 17.4 | Sucralfate and Prevention of VAP | |
| Section C. Surgery, Anesthesia, and Perioperative Medicine | ||
| 18. | Localizing Care to High-Volume Centers | |
| 19. | Learning Curves for New Procedures—the Case of Laparoscopic Cholecystectomy | |
| 20. | Prevention of Surgical Site Infections | |
| 20.1 | Prophylactic Antibiotics | |
| 20.2 | Perioperative Normothermia | |
| 20.3 | Supplemental Perioperative Oxygen | |
| 20.4 | Perioperative Glucose Control | |
| 21. | Ultrasound Guidance of Central Vein Catheterization | |
| 22. | The Retained Surgical Sponge | |
| 23. | Pre-Anesthesia Checklists To Improve Patient Safety | |
| 24. | The Impact Of Intraoperative Monitoring On Patient Safety | |
| 25. | Beta-blockers and Reduction of Perioperative Cardiac Events | |
| Section D. Safety Practices for Hospitalized or Institutionalized Elders | ||
| 26. | Prevention of Falls in Hospitalized and Institutionalized Older People | |
| 26.1 | Identification Bracelets for High-Risk Patients | |
| 26.2 | Interventions that Decrease the Use of Physical Restraints | |
| 26.3 | Bed Alarms | |
| 26.4 | Special Hospital Flooring Materials to Reduce Injuries from Patient Falls | |
| 26.5 | Hip Protectors to Prevent Hip Fracture | |
| 27. | Prevention of Pressure Ulcers in Older Patients | |
| 28. | Prevention of Delirium in Older Hospitalized Patients | |
| 29. | Multidisciplinary Geriatric Consultation Services | |
| 30. | Geriatric Evaluation and Management Units for Hospitalized Patients | |
| Section E. General Clinical Topics | ||
| 31. | Prevention of Venous Thromboembolism | |
| 32. | Prevention of Contrast-Induced Nephropathy | |
| 33. | Nutritional Support | |
| 34. | Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients | |
| 35. | Reducing Errors in the Interpretation of Plain Radiographs and Computed Tomography Scans | |
| 36. | Pneumococcal Vaccination Prior to Hospital Discharge | |
| 37. | Pain Management | |
| 37.1 | Use of Analgesics in the Acute Abdomen | |
| 37.2 | Acute Pain Services | |
| 37.3 | Prophylactic Antiemetics During Patient-controlled Analgesia Therapy | |
| 37.4 | Non-pharmacologic Interventions for Postoperative Plan | |
| Section F. Organization, Structure, and Culture | ||
| 38. | “Closed” Intensive Care Units and Other Models of Care for Critically Ill Patients | |
| 39. | Nurse Staffing, Models of Care Delivery, and Interventions | |
| 40. | Promoting a Culture of Safety | |
| Section G. Systems Issues and Human Factors | ||
| 41. | Human Factors and Medical Devices | |
| 41.1 | The Use of Human Factors in Reducing Device-related Medical Errors | |
| 41.2 | Refining the Performance of Medical Device Alarms | |
| 41.3 | Equipment Checklists in Anesthesia | |
| 42. | Information Transfer | |
| 42.1 | Information Transfer Between Inpatient and Outpatient Pharmacies | |
| 42.2 | Sign-Out Systems for Cross-Coverage | |
| 42.3 | Discharge Summaries and Follow-up | |
| 42.4 | Notifying Patients of Abnormal Results | |
| 43. | Prevention of Misidentifications | |
| 43.1 | Bar Coding | |
| 43.2 | Strategies to Avoid Wrong-Site Surgery | |
| 44. | Crew Resource Management and its Applications in Medicine | |
| 45. | Simulator-Based Training and Patient Safety | |
| 46. | Fatigue, Sleepiness, and Medical Errors | |
| 47. | Safety During Transportation of Critically Ill Patients | |
| 47.1 | Interhospital Transport | |
| 47.2 | Intrahospital Transport | |
| Section H. Role of the Patient | ||
| 48. | Procedures For Obtaining Informed Consent | |
| 49. | Advance Planning For End-of-Life Care | |
| 50. | Other Practices Related to Patient Participation | |
| PART IV. Promoting And Implementing Safety Practices | ||
| 51. | Practice Guidelines | |
| 52. | Critical Pathways | |
| 53. | Clinical Decision Support Systems | |
| 54. | Educational Techniques Used in Changing Provider Behavior | |
| 55. | Legislation, Accreditation, and Market-Driven and Other Approaches to Improving Patient Safety | |
| PART V. Analyzing The Practices | ||
| 56. | Methodology for Summarizing the Evidence for the Practices | |
| 57. | Practices Rated by Strength of Evidence | |
| 58. | Practices Rated by Research Priority | |
| 59. | Listing of All Practices, Categorical Ratings, and Comments | |