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

Chapter 37. Pain Management.............................................................................................396
Subchapter 37.1. Use of Analgesics in the Acute Abdomen ...........................................396
Subchapter 37.2. Acute Pain Services..............................................................................400
Subchapter 37.3. Prophylactic Antiemetics During Patient-controlled Analgesia Therapy
...........................................................................................................................................404
Subchapter 37.4. Non-pharmacologic Interventions for Postoperative Plan ...................406
Section F. Organization, Structure, and Culture ....................................................................411
Chapter 38. “Closed” Intensive Care Units and Other Models of Care for Critically Ill
Patients..................................................................................................................................413
Chapter 39. Nurse Staffing, Models of Care Delivery, and Interventions ..........................423
Chapter 40. Promoting a Culture of Safety ..........................................................................447
Section G. Systems Issues and Human Factors ......................................................................458
Chapter 41. Human Factors and Medical Devices ..............................................................459
Subchapter 41.1. The Use of Human Factors in Reducing Device-related Medical Errors
...........................................................................................................................................459
Subchapter 41.2. Refining the Performance of Medical Device Alarms .........................462
Subchapter 41.3. Equipment Checklists in Anesthesia....................................................466
Chapter 42. Information Transfer.........................................................................................471
Subchapter 42.1. Information Transfer Between Inpatient and Outpatient Pharmacies..471
Subchapter 42.2. Sign-Out Systems for Cross-Coverage ................................................476
Subchapter 42.3. Discharge Summaries and Follow-up ..................................................479
Subchapter 42.4. Notifying Patients of Abnormal Results ..............................................482
Chapter 43. Prevention of Misidentifications......................................................................487
Subchapter 43.1. Bar Coding ...........................................................................................487
Subchapter 43.2. Strategies to Avoid Wrong-Site Surgery..............................................494
Chapter 44. Crew Resource Management and its Applications in Medicine......................501
Chapter 45. Simulator-Based Training and Patient Safety..................................................511
Chapter 46. Fatigue, Sleepiness, and Medical Errors..........................................................519
Chapter 47. Safety During Transport of Critically Ill Patients............................................534
Subchapter 47.1. Interhospital Transport ..........................................................................536
Subchapter 47.2. Intrahospital Transport .........................................................................538
Section H. Role of the Patient.................................................................................................544
Chapter 48. Procedures For Obtaining Informed Consent ..................................................546
Chapter 49. Advance Planning For End-of-Life Care.........................................................556
Chapter 50. Other Practices Related to Patient Participation ..............................................569
PART IV. PROMOTING AND IMPLEMENTING SAFETY PRACTICES .......................................573
Chapter 51. Practice Guidelines ..........................................................................................575
Chapter 52. Critical Pathways .............................................................................................581
Chapter 53. Clinical Decision Support Systems..................................................................589
Chapter 54. Educational Techniques Used in Changing Provider Behavior.......................595
Chapter 55. Legislation, Accreditation, and Market-Driven and Other Approaches to
Improving Patient Safety......................................................................................................601
ix