Making Health Care Safer II: Updated Critical Analysis of Evidence for Patient Safety

[NRSKarenRN, BSN, RN]

Agency for Healthcare Research and Quality

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices

Making Health Care Safer II

An Updated Critical Analysis of the Evidence for Patient Safety Practices

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices (AHRQ Evidence Report No. 211) updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). The 2001 report analyzed the strength of evidence for patient safety practices in use at that time. The 2013 report analyzed a growing body of patient safety research to determine the level of evidence regarding the outcomes, as well as implementation, adoption, and the context in which safety strategies have been used.

After analyzing 41 patient safety practices, an international panel of patient safety experts identified 22 strategies that are ready for adoption. Enough evidence exists that health systems and institutions can move forward in implementing these strategies to improve the safety and quality of health care.

Of the 22 strategies identified in Making Health Care Safer II, 10 are "strongly encouraged" for adoption based on the strength and quality of evidence:

1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
   
2. Bundles that include checklists to prevent central line-associated bloodstream infections.
   Tools for Reducing Central Line-Associated Bloodstream Infections [www.ahrq.gov/qual/clabsitools/clabsitools.htm]
   CUSP Toolkit [www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html]
   
3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
   On the CUSP: Stop CAUTI [www.onthecuspstophai.org/on-the-cuspstop-cauti/ ]
   
4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
   
5. Hand hygiene.
   Centers for Disease Control and Prevention hand hygiene resources [www.cdc.gov/handhygiene/]
   Department of Veterans Affairs hand hygiene resources [www.patientsafety.gov/SafetyTopics/HandHygiene/index.html#tools]
   
6. "Do Not Use" list for hazardous abbreviations.
   The Joint Commission, Facts About the Official "Do Not Use" List [ www.jointcommission.org/about_us/patient_safety_fact_sheets.aspx ]
   
7. Multicomponent interventions to reduce pressure ulcers.
   The On-Time Quality Improvement for Long-Term Care [www.ahrq.gov/research/ontime.htm]
   
8. Barrier precautions to prevent healthcare-associated infections.
   Tools for Reducing Central Line-Associated Bloodstream Infections [www.ahrq.gov/qual/clabsitools/clabsitools.htm]
   
9. Use of real-time ultrasound for central line placement.
   Tools for Reducing Central Line-Associated Bloodstream Infections [www.ahrq.gov/qual/clabsitools/clabsitools.htm]
   
10. Interventions to improve prophylaxis for venous thromboembolisms.
    Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement [www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html]
    Blood Thinner Pills: Your Guide to Using them Safely [www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/index.html]
    Your Guide to Preventing and Treating Blood Clots [www.ahrq.gov/patients-consumers/prevention/disease/bloodclots.html]
    

To access Making Health Care Safer II (AHRQ Evidence Report No. 211), go to www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

To access Making Health Care Safer (AHRQ Evidence Report No. 43), go to http://archive.ahrq.gov/clinic/ptsafety/.