Chapter 3. Evidence-based Review Methodology

For this project the UCSF-Stanford Evidence-based Practice Center (EPC) 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 conditions or procedures.” Examples of practices that meet this definition include computerized physician order entry (Chapter 6), thromboembolism prophylaxis in hospitalized patients (Chapter 31), strategies to reduce falls among hospitalized elders (Chapter 26), and novel education strategies such as the application of “crew resource management” to train operating room staff (Chapter 44). By contrast, practices that are disease-specific and/or directed at the underlying disease and its complications (eg, use of aspirin or beta-blockers to treat acute myocardial infarction) rather than complications of medical care are not included as “patient safety practices.” Further discussion of these issues can be found in Chapter 1. In some cases, the distinction between patient safety and more general quality improvement strategies is difficult to discern. Quality improvement practices may also qualify as patient safety practices when the current level of quality is considered “unsafe,” but standards to measure safety are often variable, difficult to quantify, and change over time. For example, what constitutes an “adequate” or “safe” level of accuracy in electrocardiogram or radiograph interpretation? Practices to improve performance to at least the “adequate” threshold may reasonably be considered safety practices because they decrease the number of diagnostic errors of omission. On the other hand, we considered practices whose main intent is to improve performance above this threshold to be quality improvement practices. An example of the latter might be the use of computer algorithms to improve the sensitivity of screening mammography. We generally included practices that involved acute hospital care or care at the interface between inpatient and outpatient settings. This focus reflects the fact that the majority of the safety literature relates to acute care and the belief that systems changes may be more effectively achieved in the more controlled environment of the hospital. However, practices that might be applicable in settings in addition to the hospital were not excluded from consideration. For example, the Report includes practices for preventing decubitus ulcers (Chapter 27) that could be applied in nursing homes as well as hospitals. The EPC team received input regarding the scope of the Report from the Agency for Healthcare Research and Quality (AHRQ), which commissioned the report. In addition, the EPC team participated in the public meeting of the National Quality Forum (NQF) Safe Practices Committee on January 26, 2001. The NQF was formed in 1999 by consumer, purchaser, provider, health plan, and health service research organizations to create a national strategy for quality improvement. Members of the Safe Practices Committee collaborated with the EPC team to develop the scope of work that would eventually become this Report.