Evidence Summary

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Key messages from scientific research that's ready to be acted on

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A review of patient safety practices recommends the adoption of 22 practices

Shekelle PG, Wachter RM, Pronovost PJ, et al. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evid Rep Technol Assess. 2013;211:1-955.

Review question

What is the evidence on the effectiveness, implementation, and adoption of patient safety practices?


Patient safety practices try to protect people from adverse events caused by health care services (including tests and treatments).

In 2001, the Agency for Healthcare Research and Quality (AHRQ) published the report Making Health Care Safer: A Critical Analysis of Patient Safety Practices. In it, health care organizations were asked to adopt safe practices to avoid preventable harm.

This AHRQ report updates the 2001 report on the state of patient safety practices.

How the review was done

This summary is based on a review of 41 patient safety practices (from an initial list of 100). The review includes published and unpublished studies since 2001, and the judgments of a 20-member committee of patient safety experts.

18 practices were assessed through in-depth reviews (that included systematic reviews) and 23 through brief reviews.

The review considered frequency and severity of the safety problem, effectiveness of patient safety practice, potential risks, costs, and implementation of the practices.

What the researchers found

20 patient safety practices had adequate evidence of effectiveness, and 25 had adequate evidence on how to implement them.

The following 10 practices had sufficient evidence for effectiveness and implementation as to be strongly recommended:

  • Checklists before surgery and anesthesia to prevent adverse events during and after surgery.
  • Checklists to prevent blood infections related to the insertion of central tubes (catheters).
  • Interventions to reduce the use of urinary catheters (including catheter reminders, doctors’ orders on when to take them out, and nurse-initiated removal protocols).
  • Procedures for lifting head-of-bed, breaks from sedatives, antimicrobial oral care, and drainage tubes to prevent pneumonia due to ventilators.
  • Hand washing.
  • Lists of dangerous abbreviations not to be used.
  • Provisions to reduce pressure ulcers of the skin.
  • Precautions to prevent health care infections.
  • Simultaneous ultrasound for inserting central catheters.
  • Interventions to prevent vein clots.

Another 12 practices had acceptable evidence as to be recommended for adoption.


The evidence for 22 patient safety practices is strong enough for health care providers to consider their immediate adoption.


Brief review
A review conducted by a content expert that includes focused literature searches for evidence related to the practice but NOT systematic reviews.
In-depth review
A review that includes both systematic reviews and AHRQ 8 Criteria for evaluating patient safety practices. AHRQ = Agency for Healthcare Research and Quality.
Systematic review
A comprehensive evaluation of the available research evidence on a particular topic.

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