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Clinician Article

Making health care safer II: an updated critical analysis of the evidence for patient safety practices.



  • Shekelle PG
  • Wachter RM
  • Pronovost PJ
  • Schoelles K
  • McDonald KM
  • Dy SM, et al.
Evid Rep Technol Assess (Full Rep). 2013 Mar;(211):1-945. (Review)
PMID: 24423049
Read abstract Read evidence summary Read full text
Disciplines
  • Geriatrics
    Relevance - 7/7
    Newsworthiness - 6/7
  • Anesthesiology
    Relevance - 7/7
    Newsworthiness - 5/7
  • Surgery - General
    Relevance - 6/7
    Newsworthiness - 6/7
  • FM/GP/Mental Health
    Relevance - 6/7
    Newsworthiness - 5/7
  • Hematology
    Relevance - 6/7
    Newsworthiness - 5/7
  • Hemostasis and Thrombosis
    Relevance - 6/7
    Newsworthiness - 5/7
  • Infectious Disease
    Relevance - 6/7
    Newsworthiness - 5/7
  • Nephrology
    Relevance - 6/7
    Newsworthiness - 5/7
  • Pediatric Emergency Medicine
    Relevance - 6/7
    Newsworthiness - 5/7
  • Cardiology
    Relevance - 5/7
    Newsworthiness - 5/7
  • Hospital Doctor/Hospitalists
    Relevance - 5/7
    Newsworthiness - 5/7
  • Internal Medicine
    Relevance - 5/7
    Newsworthiness - 5/7
  • Pediatrics (General)
    Relevance - 5/7
    Newsworthiness - 5/7
  • Emergency Medicine
    Relevance - 5/7
    Newsworthiness - 4/7
  • Intensivist/Critical Care
    Relevance - 5/7
    Newsworthiness - 4/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 4/7
    Newsworthiness - 4/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 4/7
    Newsworthiness - 4/7
  • Psychiatry
    Relevance - 4/7
    Newsworthiness - 3/7

Abstract

OBJECTIVES: To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

DATA SOURCES: Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.

REVIEW METHODS: The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption.

RESULTS: From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption.

CONCLUSIONS: The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.


Clinical Comments

Anesthesiology

The article "Making Health Care Safer II: An Updated Critical Analysis is a must read for practitioners. The 5 page review does not provide much if any information but talks about the process of gathering and vetting information. The main body of work, all 955 pages contains pertinent information about safety practices and gives reviews about which should be adopted immediately and which need more research. 18 have in-depth reviews and 23 brief reviews. 10 practices had sufficient evidence for immediate implementation and adoption and an additional 12 practices were classified as encouraged for adoption. This should be used as a reference for safety practices. Not all pertain to anesthesia, but the ones that do are pertinent and should be adopted to improve patient safety. Many of these practices have already been adopted at many institutions.

Emergency Medicine

A great source of information for those in positions of responsibility for ensuring that evidence based PSPs are in place in their institutions.

Family Medicine (FM)/General Practice (GP)

Although safer working practices concern us all, this review is almost entirely concerned with hospital-based care.

Geriatrics

This is a thorough systematic review of patient safety interventions written by a who's-who in the field of patient safety. The full review is lengthy but worthwhile background material for future studies of patient safety initiatives.

Geriatrics

The concept of “To Err is Human” permitted to accept nearly a hundred thousands of deaths per year from medical errors in the US by the year 1999. Probably, this was the origin of the modern patient safety movement that this AHQR’s report represents. Based on systematic reviews, meta-analysis and clinical trials, this PSPs represent practices that health care providers can consider for adoption now. But we have to take in mind that the chapters relied on the judgment of their team of authors. Therefore, the results are, in part, a product of these judgments as on the systematic review methods.

Hematology

A great deal of effort has gone into improving patient safety in the hospitals with which I am associated. That work continues as it should. Studies like this one are helpful.

Intensivist/Critical Care

The methods of promoting patient safety are becoming more rigorous in design and evaluation. However, it is unclear that a Cochrane collaboration contribution that evaluates the methods of evaluation contributes much if anything to the literature. The content is not really 'news' and has little 'intellectual' contribution. Practitioners do not need to read this.

Internal Medicine

This 1000-page summary of published evidence on patient safety practices is not directly pertinent to my diagnostic and patient management decisions for this morning's internal medicine clinic; however, it is of great interest to me in my duties in health system administration.

Nephrology

This is a difficult document for the casual reader albeit with very important material. Most relevant to nephrology are the recommendations regarding urinary catheters. The most important tables / data are found in the full document on pages ES-12 and & ES-13 or pages 30 and 31 of the 900 page document. The abstract and summary tells the clinician very little of what they need to know beyond the process by which the committee made their decisions but not what those decision are. None the less, if this information can be extracted for the typical reader, the information might be quite informative.

Psychiatry

It is heartening to know that 22 patient safety practices are better understood and could be used by practitioners.

Surgery - General

The 5 page summary doesn't really say anything, and the main document is 955 pages long. I don't know if anyone will want to read it. I didn't.

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