Practices that could improve patient safety

A new federal report identifies dozens of evidence-based practices that could improve patient safety, including a number that investigators say are not routinely performed in hospitals and other health care institutions.

The 640-page report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, was released by the federal Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, Investigators with AHRQ reviewed scientific literature to identify practices that are proven to be effective and believed to represent a significant opportunity for improving patient safety. The report mainly deals with hospital care but also includes care delivered in nursing homes, at ambulatory care sites and by patients themselves in managing their care.

Clear opportunities

Eleven of the practices highlighted in the report are called "clear opportunities" to improve patient safety but AHRQ says they are not routinely performed. They include administering antibiotics before surgery to prevent infections, using ultrasound to help guide the insertion of central intravenous lines and to prevent punctured arteries, and giving surgery patients beta-blockers to prevent heart attacks.

AHRQ investigated the issue in response to recent concerns about medical errors, generated in part by the 1999 Institute of Medicine’s (IOM) report, To Err is Human: Building a Safer Health System. That report highlighted the risks of U.S. medical care and estimated the magnitude of medical errors-related deaths at 44,000-98,000 deaths per year. The IOM report has come under fire by critics who say it overestimated the problem. (For more on that development, see "Errors in the report on medical errors?" in this issue.)

The AHRQ investigators defined a "patient safety practice" as "a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures." Its report notes that researchers now believe that most medical errors cannot be prevented by perfecting the technical work of individual doctors, nurses, or pharmacists. Improving patient safety often involves the coordinated efforts of multiple members of the health care team who may adopt strategies from outside health care.

How to choose

The report reviews several practices whose evidence came from the domains of commercial aviation, nuclear safety, aerospace, and the disciplines of human factors engineering and organizational theory. Such practices include root-cause analysis, computerized physician order entry and decision support, automated medication dispensing systems, barcoding technology, aviation-style preoperative checklists, promoting a "culture of safety," crew resource management, the use of simulators in training, and integrating human factors theory into the design of medical devices and alarms.

The National Quality Forum in Washington, DC, plans to use this report to help identify a list of patient safety practices that consumers and others should know about as they choose a health care provider. Seventy-nine practices were reviewed in detail. The following 11 patient safety practices were the most highly rated in terms of strength of the evidence supporting more widespread implementation. Practices appear in descending order, with the most highly rated practices listed first.

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.

• Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.

• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.

• Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.

• Asking that patients recall and restate what they have been told during the informed consent process.

• Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia.

• Use of pressure relieving bedding materials to prevent pressure ulcers.

• Use of real-time ultrasound guidance during central line insertion to prevent complications.

• Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications.

• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.

• Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

Tilting to the clinical

AHRQ points out that the list generally is weighted toward clinical rather than organizational matters, and toward care of the very ill rather than the mildly or chronically ill. Although more than a dozen practices considered were general safety practices that have been the focus of patient safety experts for decades (i.e., computerized physician order entry, simulators, creating a "culture of safety," crew resource management), most research on patient safety has focused on more clinical areas.

In terms of the research agenda for patient safety, the following 12 practices rated most highly:

• Improved perioperative glucose control to decrease perioperative infections.

• Localizing specific surgeries and procedures to high-volume centers.

• Use of supplemental perioperative oxygen to decrease perioperative infections.

• Changes in nursing staffing to decrease overall hospital morbidity and mortality.

• Use of silver alloy-coated urinary catheters to prevent urinary tract infections.

• Computerized physician order entry with computerized decision support systems to decrease medication errors and adverse events primarily due to the drug ordering process.

• Limitations placed on antibiotic use to prevent hospital-acquired infections due to antibiotic-resistant organisms.

• Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.

• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and post-surgical patients.

• Use of analgesics in the patient with an acutely painful abdomen without compromising diagnostic accuracy.

• Improved hand-washing compliance (via education/behavior change; sink technology and placement; or the use of antimicrobial washing substances).

AHRQ investigators say their report represents a first effort to approach the field of patient safety through the lens of evidence-based medicine.