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 |