The Agency for Healthcare Research and Quality (AHRQ) reported that despite quality improvement initiatives and significant amounts of resources invested to improve patient safety, there has been little improvement in adverse patient events from 2006 to 2008.
What is a Patient Safety Practice?
A patient safety practice is a process that reduces the probability of an adverse event.
Practice implications: Many low costs improvements can significantly improve patient outcomes
Strongly recommended best practice:
- Preoperative and anesthesia checklists are effective in preventing operative and post-operative events
- Bundles that include checklists prevents central line-associated bloodstream infections
- Interventions to reduce urinary catheter use, catheter reminders, stop orders, and catheter removal protocols decrease urinary tract infections
- Bundles that include HOB elevation, diligent oral care with chlorhexidine, subglottic-suctioning endotracheal tubes and sedation breaks reduce ventilator-associated pneumonia
- Hand hygiene
- “Do Not Use” list for hazardous abbreviations
- Multiple interventions to eliminate pressure ulcers:
- Barrier precautions to prevent healthcare-associated infections
- Use of real-time ultrasound for central line placements
- Interventions to improve prophylaxis for venous thromboembolism
- Interdisciplinary fall prevention strategies
- Use of clinical pharmacists to reduce adverse drug events
- Medication reconciliation
For more information: www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html