Evidence Report/Technology Assessment Number 43 - Making ...

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14. Robinson JL, Nash DB. Consumers' role in patient safety. QRC Advis. 2000; 17: 1-3. 15. Patient Fact Sheet. 20 Tips to Help Prevent Medical Errors (AHRQ Publication No. 00- PO38) Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/consumer/20tips.htm. Accessed June 25, 2001. 16. DoctorQuality corporate website DoctorQuality.com, Inc. Available at: http://www.doctorquality.com/www/about.asp. Accessed June 25, 2001. 17. Lerner P, Lerner J. Lerner's consumer guide to health care: how to get the best health care for less. Seattle, WA: Lerner Communications; 2001. 18. Arnot RB. The Best Medicine: How to Choose the Top Doctors, the Top Hospitals, and the Top Treatments. Reading, MA: Addison-Wesley Publishing Company; 1993. 19. Fotch E. The effect of the world wide web on you and your patients. Ophthalmol Clin North Am. 2000; 13: 261-269. 20. Bard M. How will the web affect the physician-patient relationship Interview by Marilynn Larkin. Lancet. 2000; 356: 1777. 21. Wilkes MS, Bell RA, Kravitz RL. Direct-to-consumer prescription drug advertising: trends, impact, and implications. Health Aff (Millwood). 2000; 19: 110-128. 22. Brown AB. The direct-to-consumer advertising dilemma. Patient Care 2001; 35:22-33. 2001; 35: 22-33. 23. Holt GA, Dorcheus L, Hall EL, Beck D, Ellis E, Hough J. Patient interpretation of label instructions. Am Pharm. 1992; NS32: 58-62. 24. Fletcher RH. Patient compliance with therapeutic advice: a modern view. Mt Sinai J Med. 1989; 56: 453-458. 25. Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language barriers in medicine in the United States. JAMA. 1995; 273: 724-728. 26. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274: 1677- 1682. 27. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999; 281: 545- 551. 28. Medication safety issue brief. Asking consumers for help. Part 3. Hosp Health Netw. 2001; 75: suppl 2 p. following 56. 29. Patient Confidentiality American Medical Association. Available at: http://www.amaassn.org/ama/pub/category/4610.html. Accessed June 25, 2001. 30. Grange A, Renvoize E, Pinder J. Patients' rights to access their healthcare records. Nurs Stand. 1998; 13: 41-42. 31. Nash DB, Manfredi MP, Bozarth B, Howell S. Connecting with the new healthcare consumer. Gaithersburg, MD: Aspen Publishers, Inc.; 2001. 572
PART IV. PROMOTING AND IMPLEMENTING SAFETY PRACTICES Chapter 51. Practice Guidelines Chapter 52. Critical Pathways Chapter 53. Clinical Decision Support Systems Chapter 54. Educational Techniques Used in Changing Provider Behavior Chapter 55. Legislation, Accreditation, and Market-Driven and Other Approaches to Improving Patient Safety 573
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Evidence Report/Technology Assessme
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Structured Abstract Objectives: Pat
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CONTENTS Summary...................
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Chapter 37. Pain Management........
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Summary Overview Patient safety has
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from the domains of commercial avia
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section above. The editorial team c
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Clear Opportunities for Research Un
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Evidence Report
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Chapter 1. An Introduction to the R
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The Evidence Chapter 3 describes ou
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never occur. Although some of these
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• Potential for Harm - Many pract
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• John W. Gosbee, MD, MS, Directo
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23. Brennan TA, Leape LL, Laird NM,
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As outlined in Chapter 24, signific
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21. Roberts KH, Libuser C. From Bho
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literature and were meant to be as
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Table 3.3. Hierarchy of study desig
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Table 3.5. Ten Required Abstraction
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References 1. Thurfjell E, Thurfjel
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PART II. REPORTING AND RESPONDING T
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Incident reports may target events
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Opportunities for Impact Most hospi
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incident reporting and analysis cou
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References 1. Brennan TA, Leape LL,
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41. Weingart SN, Ship AN, Aronson M
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Despite legitimate concerns about t
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Evidence for Effectiveness of the P
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17. Rasmussen J. Human error and th
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Section A. Adverse Drug Events (ADE
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Prevalence and Severity of the Targ
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egimen 27 (Level 2); another study
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few data describing reductions in A
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Table 6.2. Studies of clinical deci
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15. Bates DW, Boyle DL, Vander Vlie
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Chapter 7. The Clinical Pharmacist
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Table 7.1. Studies of clinical phar
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18. Beney J, Bero LA, Bond C. Expan
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to alert the monitoring clinician i
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Comment Computerized real-time moni
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References 1. Kellaway GS, McCrae E
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Chapter 9. Protocols for High-Risk
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egarded as a case-control study. 29
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Comment The primary purpose of hepa
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Table 9.1. Studies focused primaril
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Table 9.2. Inpatient anticoagulatio
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References 1. Bates DW, Cullen DJ,
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37. Ellis RF, Stephens MA, Sharp GB
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Chapter 10. Unit-Dose Drug Distribu
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Study Designs The 5 studies meeting
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hospitals that wish to do much of t
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When wrong time errors were omitted
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21. Barker KN, McConnell WE. The pr
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Chapter 11. Automated Medication Di
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system. 5 We classified this as a L
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Table 11.1. Six studies reviewing a
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117
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Chapter 12. Practices to Improve Ha
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interventions to assess effectivene
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Table 12.1. Fourteen studies of pra
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References 1. Haley RW, Culver DH,
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Chapter 13. Impact of Barrier Preca
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poor, 20 often below 50%. 21 Purpor
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the annual expenses due directly to
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254-bed long-term care facility in
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Table 13.2. Studies of barrier prec
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References 1. Handwerger S, Raucher
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35. Gammon J. The psychological con
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Chapter 14. Impact of Changes in An
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Table 14.1. Before-after studies of
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18. MacGowan AP, Brown I, Feeney R,
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Chapter 15. Prevention of Nosocomia
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Table 15.1.1. Studies of silver all
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9. Kunin CM. Urinary Tract Infectio
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probably appropriate to use since i
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Table 15.2.1. Prospective studies c
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6. Saint S, Veenstra DL, Sullivan S
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Chapter 16. Prevention of Intravasc
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Prevention Unnecessarily prolonged
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Table 16.1.1. Studies of vascular c
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Subchapter 16.2. Use of Central Ven
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Comment In light of the substantial
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Ramsay 41 §: 397 hospital patients
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Subchapter 16.3. Use of Chlorhexidi
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Table 16.3.1. Characteristics of st
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support the routine use of tunnelin
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32. Maki DG, Stolz SM, Wheeler S, M
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Final Comment to Chapter 16 Infecti
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Chapter 17. Prevention of Ventilato
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Potential for Harm No adverse effec
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Table 17.1.1. Patient positioning*
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Opportunities for Impact Continuous
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Table 17.2.1. Randomized trials of
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total antibiotic costs. 14-16 decre
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References 1. D'Amico R, Pifferi S,
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Table 17.4.1. Studies of stress ulc
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12. Slaughter S, Hayden MK, Nathan
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Chapter 18. Localizing Care to High
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showed an association) and physicia
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In addition to the potential use of
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References 1. Luft HS, Bunker JP, E
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Chapter 19. Learning Curves for New
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Thus, determination of a minimum nu
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References 1. Gallstones and laparo
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39. Crawford DL, Phillips EH. Lapar
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Chapter 20. Prevention of Surgical
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Costs and Implementation A number o
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• Single dose vs. multiple dose r
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All Cesarean section: RR 0.37 (0.33
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17. Vegas AA, Jodra VM, Garcia ML.
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Subchapter 20.2. Perioperative Norm
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Comment Given the evidence of effec
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Opportunities for Impact Administra
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5. Greif R, Laciny S, Rapf B, Hickl
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Table 20.4.1. Prospective, before-a
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29. Lazar HL, Chipkin S, Philippide
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Chapter 21. Ultrasound Guidance of
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after 1996 9,15,17 and one that inc
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Comment Real-time US guidance for C
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References 1. Civetta JM, Taylor RW
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38. Kaufmann C, Rhee P, Burris D. T
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Chapter 22. The Retained Surgical S
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prevalence of this error and the ef
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Chapter 23. Pre-Anesthesia Checklis
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to anesthesia providers’ own meth
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References 1. Reason JT. Human Erro
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Chapter 24. The Impact Of Intraoper
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complications. During anesthesia an
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References 1. American Society of A
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Chapter 25. Beta-blockers and Reduc
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27 Accounting for these differences
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The use of beta-blockers to reduce
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defined as systolic blood pressure
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28. Litwack R, Gilligan D, DeGrutto
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Chapter 26. Prevention of Falls in
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facilities and a 31% reduction in m
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as to whether identification bracel
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36. Mitchell A, Jones N. Striving t
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has been good. In fact, given adequ
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References 1. Health Care Financing
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Table 26.3.1. Study of bed alarms f
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Table 26.4. Study of special floori
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Costs and Implementation An Austral
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7. Lauritzen JB, Petersen MM, Lund
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Chapter 27. Prevention of Pressure
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employed, ranging from Grade 1 (dis
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5. Norton D, McLaren R, Exton-Smith
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Chapter 28. Prevention of Delirium
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aseline co-morbidities of the enrol
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References 1. Elie M, Cole MG, Prim
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Chapter 29. Multidisciplinary Geria
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Study Outcomes Ten studies reported
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experienced geriatric team in a hos
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Marcantoni 126 orthopedic patients
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19. Gayton D, Wood-Dauphinee S, de
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Chapter 30. Geriatric Evaluation an
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Cognitive function, as measured by
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Table 30.1. Randomized Controlled T
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References 1. Creditor MC. Hazards
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Section E. General Clinical Topics
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Chapter 31. Prevention of Venous Th
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patients, the incidence of DVT was
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data show that aspirin (6 studies,
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Medical Patients VTE prevention in
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LMWH was more cost-effective than L
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Table 31.1. Mechanical and pharmaco
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Table 31.3. Recommended VTE prophyl
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17. Vanek VW. Meta-analysis of effe
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Chapter 32. Prevention of Contrast-
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the studies used aminophylline, rat
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Table 32.1. Studies of strategies f
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References 1. Parfrey PS, Griffiths
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33. Tippins RB, Torres WE, Baumgart
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Chapter 33. Nutritional Support Nei
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developing major infectious complic
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Table 33.1. Studies evaluating nutr
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19. Moore FA, Moore EE, Jones TN, M
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literature during that time. 17 Ide
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Costs and Implementation One cost-e
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6. Beejay U, Wolfe M. Acute gastroi
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375
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inferior to film interpretation for
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Study Outcomes Most studies reporte
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Table 35.1. Educational interventio
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31. Herman PG, Gerson DE, Hessel SJ
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Chapter 36. Pneumococcal Vaccinatio
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andomized controlled trials (RCTs)
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All studies of the effectiveness of
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Table 36.1. 1. Pneumococcal vaccine
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9. Whitney CG, Farley MM, Hadler J,
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395
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surgeons indicate that the majority
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Table 37.1.1. Randomized controlled
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anesthesiologists, specially traine
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Table 37.2.1. Studies of acute pain
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Opportunities for Impact The degree
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Practice Description Non-pharmacolo
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Table 37.4.1. Studies of non-pharma
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Section F. Organization, Structure,
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Chapter 38. “Closed” Intensive
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pediatric multidisciplinary ICUs. I
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adjusted hospital mortality and a n
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RRR is the unadjusted mortality rel
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19. DiCosmo BFM. Addition of an int
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Chapter 39. Nurse Staffing, Models
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interventions to reduce pain, nause
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al 30 also does not find an associa
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associated with in-hospital mortali
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Table 39.3 Structural measures: ava
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8. Data from HCFA Medicare Level 3,
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Table 39.4 Structural variables: nu
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Table 39.5 Process measures: nurse
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10. Finnigan SA, Abel M, Dobler T,
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50. Kite K. Changing mouth care pra
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91. Medicare. Available at: www.sta
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138. Jones J, Rowan K. Is there a r
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Chapter 40. Promoting a Culture of
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organizational culture in high reli
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vary, depending on the type of acci
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Table 40.1. Checklist of elements t
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References 1. Roberts KH, Gargano G
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42. Helmreich RL. On error manageme
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Chapter 41. Human Factors and Medic
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Device Evaluation Prior to Purchase
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Identification of Alarm Source and
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Decreasing the Frequency of Alarms
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checklists in medicine have been li
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31. Stanford L, McIntyre J, Hogan J
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Chapter 42. Information Transfer Ha
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surveyed also wished to be provided
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Table 42.1.1. Practices to improve
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adverse medical event occurring dur
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Table 42.2.1. Computerized sign-out
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Costs and Implementation The direct
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Practice Description Our search rev
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Table 42.4.1. Randomized controlled
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Chapter 43. Prevention of Misidenti
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Medical record keeping Radiology an
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Study Outcomes Some of the studies
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References 1. Rappoport A. A hospit
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payments in 84% of cases, compared
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12. Cowell HR. Wrong-site surgery.
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Chapter 44. Crew Resource Managemen
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Representative Studies Several stud
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on Crisis Management Training in He
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practice, relatively little about t
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21. Halamek LP, Kaegi DM, Gaba DM,
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Chapter 45. Simulator-Based Trainin
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e difficult, 19 initial work has be
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factors that contribute to negative
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25. Sica GT, Barron DM, Blum R, Fre
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Chapter 46. Fatigue, Sleepiness, an
Page 531 and 532: fellowships. 34, 35 These shifts ar
Page 533 and 534: patient outcomes. Any effort to cha
Page 535 and 536: hour prophylactic nap in the evenin
Page 537 and 538: 11. Cox T K, GP, ed. Stress and Sus
Page 539 and 540: 53. Overland DW. Comparison of Effe
Page 541 and 542: 97. Nicholson AN, Pascoe PA, Roehrs
Page 543 and 544: 533
Page 545 and 546: eceive special training in skills n
Page 547 and 548: availability and different scoring
Page 549 and 550: Potential for Harm Inadequate maint
Page 551 and 552: Table 47.2 Manual versus mechanical
Page 553 and 554: 20. Duke G, Green J. Outcome of cri
Page 555 and 556: 545
Page 557 and 558: Legislation governing the requireme
Page 559 and 560: obtaining informed consent often re
Page 561 and 562: patients that had been treated surg
Page 563 and 564: References 1. Edwards SJ, Lilford R
Page 565 and 566: 555
Page 567 and 568: Failure to Document Preferences The
Page 569 and 570: Evidence for Effectiveness of the P
Page 571 and 572: have demonstrated that most medical
Page 573 and 574: Costs and Implementation Estimating
Page 575 and 576: References 1. Jonsen AR SM, Winslad
Page 577 and 578: 39. Kurent J. Death and Dying in Am
Page 579 and 580: Chapter 50. Other Practices Related
Page 581: analyzed these competing views, and
Page 585 and 586: Chapter 51. Practice Guidelines Rob
Page 587 and 588: Evidence for Effectiveness of Pract
Page 589 and 590: 4. Weingarten S. Using practice gui
Page 591 and 592: Chapter 52. Critical Pathways Rober
Page 593 and 594: not reach statistical significance)
Page 595 and 596: Table 52.1. Key features of studies
Page 597 and 598: 19. Willis B, Kim LT, Anthony T, Be
Page 599 and 600: Chapter 53. Clinical Decision Suppo
Page 601 and 602: A final systematic review analyzed
Page 603 and 604: Costs and Implementation Very few s
Page 605 and 606: Chapter 54. Educational Techniques
Page 607 and 608: interventions with at least 3 compo
Page 609 and 610: Table 54.1. Studies of techniques f
Page 611 and 612: Chapter 55. Legislation, Accreditat
Page 613 and 614: hospitals and other health care ins
Page 615 and 616: for bias, particularly when the rec
Page 617 and 618: Table 55.2. A comparison of non-loc
Page 619 and 620: 21. Yessian M. The external review
Page 621 and 622: PART V. ANALYZING THE PRACTICES Cha
Page 623 and 624: Chapter 56. Methodology for Summari
Page 625 and 626: Details about Decision Rules and Ju
Page 627 and 628: determining the specific elements t
Page 629 and 630: Chapter 57. Practices Rated by Stre
Page 631 and 632: Table 57.2 Patient Safety Practices
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17.1 Ventilator-associated pneumoni
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57.5 Patient Safety Practices with
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Chapter 58. Practices Rated by Rese
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9 Adverse events related to anticoa
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42.4 Failures to communicate signif
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Chapter 59. Listing of All Practice
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Ch. # Patient Safety Target 16.4 Ce
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Ch. # Patient Safety Target Patient
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Ch. # Patient Safety Target Patient
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Comments Section 1 Medium strength
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29 High complexity for implementati
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55 Rated as low, but this practices
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84 Most evidence available outside
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Appendix: List of Contributors Edit
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Sharon K. Inouye, MD, MPH Associate
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Jean Ann Seago, PhD, RN Assistant P
Page 665 and 666:
Index abdominal pain, acute analges
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described, 601 research needs, 604
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Natural Death Acts, 561 nursing iss
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decision rules and judgment conside
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