Structured Abstract

Contents

• Preface
• Authors and Affiliations
• Acknowledgments
• Additional Contributors
• Executive Summary
• Part 1. Overview
  • Chapter 1. Introduction
    • Who Will Use This Report, and for What Purpose?
    • References
  • Chapter 2. Methods
    • Topic Development
    • Project Overview
    • Topic Refinement
    • Evidence Assessment Framework
    • Evidence Review Process
    • Assessing Quality of Individual Studies
    • Assessing Strength of Evidence for a Patient Safety Practice
    • Summarizing the Evidence
    • Setting Priorities for Adoption of Patient Safety Practices
    • Future Research Needs
    • Peer and Public Review Process
    • References
• Part 2. Evidence Reviews of Patient Safety Practices
• Part 2a. Practices Designed for a Specific Patient Safety Target
  • Section A. Adverse Drug Events
    • Chapter 3. High-Alert Drugs: Patient Safety Practices for Intravenous Anticoagulants
      Elizabeth Pfoh, MPH, David Thompson, DNSc, MS, RN, and Sydney Dy, MD, MSc.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About the Effect of Context on Effectiveness?
      • Conclusions and Comment
      • References
    • Chapter 4. Clinical Pharmacist's Role in Preventing Adverse Drug Events: Brief Update Review
      Peter Glassman, MBBS, MSc.
      • Introduction
      • What is the Role of the Clinical Pharmacist in Preventing Adverse Drug Events?
      • What Have We Learned About the Role of Clinical Pharmacists?
      • Conclusions and Comment
      • References
    • Chapter 5. The Joint Commission's “Do Not Use” List: Brief Review (NEW)
      Peter Glassman, MBBS, MSc.
      • Introduction
      • What Are the Procedures for Reducing Prescribing Errors?
      • How Effective Have These Procedures Been?
      • What Have We Learned About Procedures for Reducing Prescribing Errors?
      • Conclusions and Comment
      • References
    • Chapter 6. Smart Pumps and Other Protocols for Infusion Pumps: Brief Review (NEW)
      James Reston, PhD, MPH.
      • Introduction
      • What Are the Practices for Reducing IV Medication Errors?
      • How Have These Practices Been Implemented?
      • What Have We Learned About These Practices?
      • Conclusions and Comment
      • References
  • Section B. Infection Control
    • Chapter 7. Barrier Precautions, Patient Isolation, and Routine Surveillance for Prevention of Health Care-Associated Infections: Brief Update Review
      Marin Schweizer, PhD.
      • Introduction
      • What Are Infection Prevention Measures?
      • What Have We Learned About Infection Control Practices Since the Original Report?
      • What Methods of Infection Control Are Currently Being Studied?
      • Conclusions and Comment
      • References
    • Chapter 8. Interventions To Improve Hand Hygiene Compliance: Brief Update Review
      Elizabeth Pfoh, MPH, Sydney Dy, MD, MSc, and Cyrus Engineer, DrPH.
      • Introduction
      • What Is Hand Hygiene Compliance?
      • How Have Interventions To Improve Hand Hygiene Compliance Been Implemented?
      • What Have We Learned About Hand Hygiene Interventions?
      • What Methods Have Been Used To Improve Hand Hygiene Compliance?
      • Conclusions and Comment
      • References
    • Chapter 9. Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections: Brief Update Review
      Jennifer Meddings, MD, MSc, Sarah L Krein, PhD, RN, Mohamad G Fakih, MD, MPH, Russell N Olmsted, MPH, CIC, and Sanjay Saint, MD, MPH.
      • Introduction
      • What Strategies May Prevent Catheter-Associated Urinary Tract Infections?
      • What Strategies May Reduce Unnecessary Catheter Use?
      • What Is the Impact of Strategies To Avoid Unnecessary Urinary Catheter Use?
      • What Is the Cost of Implementing a CAUTI Prevention Program?
      • What Methods Have Been Used To Improve the Implementation of Interventions To Prevent Catheter-Associated Urinary Tract Infections?
      • Monitoring and Providing Feedback on Catheter Use and CAUTI Rates
      • Conclusions and Comment
      • References
    • Chapter 10. Prevention of Central Line-Associated Bloodstream Infections: Brief Update Review
      Vineet Chopra, MD, MSc, Sarah L Krein, PhD, RN, Russell N Olmsted, MPH, CIC, Nasia Safdar, MD, PhD, and Sanjay Saint, MD, MPH.
      • Introduction
      • What Practices Are Associated With CLABSI Prevention?
      • How Has CLABSI Prevention Been Implemented?
      • What Have We Learned About CLABSI Prevention?
      • Conclusions and Comment
      • References
    • Chapter 11. Ventilator-Associated Pneumonia: Brief Update Review
      Bradford D Winters, PhD, MD and Sean M Berenholtz, MD, MHS.
      • Introduction
      • What Are the Patient Safety Practices for Preventing Ventilator-Acquired Pneumonia?
      • How Have Practices To Prevent Ventilator-Acquired Pneumonia Been Implemented and What Has Been Learned?
      • Conclusions and Comment
      • References
    • Chapter 12. Interventions To Allow the Reuse of Single-Use Devices: Brief Review (NEW)
      Meredith Noble, MS.
      • Introduction
      • What Are the Practices for Assuring the Safety of Reused Devices?
      • How Have These Practices Been Implemented?
      • What Have We Learned About These Practices?
      • What Methods Have Been Used To Improve These Practices?
      • Conclusions and Comment
      • References
  • Section C. Surgery, Anesthesia, and Perioperative Medicine
    • Chapter 13. Preoperative Checklists and Anesthesia Checklists
      Jonathan R Treadwell, PhD and Scott Lucas, PhD, PE.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About Adoption and Diffusion of This Patient Safety Practice?
      • Conclusions and Comment
      • References
    • Chapter 14. Use of Report Cards and Outcome Measurements To Improve Safety of Surgical Care: American College of Surgeons National Quality Improvement Program (NEW)
      Melinda Maggard-Gibbons, MD, MSHS.
      • How Important Is the problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About the Effect of Context on Effectiveness? Lessons Learned From Implementation at Different Sites
      • Conclusions and Comment
      • References
    • Chapter 15. Prevention of Surgical Items Being Left Inside Patient: Brief Update Review
      Jonathan R Treadwell, PhD.
      • Introduction
      • What Are the Practices Aimed at the Prevention of Leaving Surgical Items Inside Patients?
      • What Supplementary Methods Have Been Used To Improve Counts of Surgical Items?
      • What Have We Learned About Methods To Improve Counts of Surgical Items?
      • Conclusions and Comment
      • References
    • Chapter 16. Operating Room Integration and Display Systems: Brief Review (NEW)
      Fang Sun, MD, PhD.
      • Introduction
      • What Are the Practices for Integrating Operating-Room Display Systems?
      • How Have Integrated Operating-Room Display Systems Been Implemented?
      • What Have We Learned About Integrating Operating-Room Display Systems?
      • Conclusions and Comment
      • References
    • Chapter 17. Use of Beta Blockers To Prevent Perioperative Cardiac Events: Brief Update Review
      Sumant R Ranji, MD and Paul G Shekelle, MD, PhD.
      • Introduction
      • What Have We Learned About the Use of Beta Blockers To Reduce the Risk of Perioperative Cardiac Events?
      • Conclusions and Comment
      • References
    • Chapter 18. Use of Real-Time Ultrasound Guidance During Central Line Insertion: Brief Update Review
      Paul G Shekelle, MD, PhD and Paul Dallas, MD.
      • Introduction
      • What Is the Practice of Using Ultrasound Guidance for Central Venous Catheter Insertion?
      • How Has the Use of Ultrasound To Guide Central Venous Catheter Insertion Been Implemented?
      • What Have We Learned About the Use of Ultrasound Guidance for Central Venous Catheter Insertion?
      • Conclusions and Comment
      • References
  • Section D. Safety Practices Aimed Primarily at Hospitalized Elders
    • Chapter 19. Preventing In-Facility Falls
      Isomi M Miake-Lye, BA, Susanne Hempel, PhD, David A Ganz, MD, PhD, and Paul G Shekelle, MD, PhD.
      • How Important Is the Problem?
      • What is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About the Effect of Context on Effectiveness?
      • Conclusions and Comment
      • References
    • Chapter 20. Preventing In-Facility Delirium
      James Reston, PhD, MPH.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • What Is Known About the Effect of Context on Outcomes?
      • Conclusions and Comment
      • References
  • Section E. General Clinical Topics
    • Chapter 21. Preventing In-Facility Pressure Ulcers
      Nancy Sullivan, BA.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs of Pressure Ulcer Prevention Programs?
      • What Is Known About the Effect of Context on Outcomes?
      • Conclusions and Comment
      • References
    • Chapter 22. Inpatient Intensive Glucose Control Strategies To Reduce Death and Infection (NEW)
      Devan Kansagara, MD, MCR, FACP.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About the Effect of Context on Effectiveness?
      • Conclusions and Comment
      • References
    • Chapter 23. Interventions To Prevent Contrast-Induced Acute Kidney Injury
      Sumant R Ranji, MD, Stephanie Rennke, MD, Yimdriuska Magan, BS, Erika Moseson, MD, and Robert M Wachter, MD.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs of the Patient Safety Practice?
      • Are There Any Data About the Effect of Context on Effectiveness?
      • Conclusions and Comment
      • References
    • Chapter 24. Rapid-Response Systems (NEW)
      Bradford D Winters, MD, PhD, Sallie Weaver, PhD, and Sydney Dy, MD, MSc.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • Why Should This Patient Safety Practice Work?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • Are There Any Data About Costs?
      • Are There Any Data About the Effect of Context on Effectiveness?
      • Conclusions and Comment
      • References
    • Chapter 25. Medication Reconciliation Supported by Clinical Pharmacists (NEW)
      Lisha Lo, MPH, Janice Kwan, MD, Olavo A Fernandes, BScPhm, PharmD, and Kaveh G Shojania, MD.
      • How Important Is the Problem?
      • What Is the Patient Safety Practice?
      • What Are the Beneficial Effects of the Patient Safety Practice?
      • What Are the Harms of the Patient Safety Practice?
      • How Has the Patient Safety Practive Been Implemented, and in What Context?
      • Are There Any Data About the Effect of Context On Effectiveness?
      • Are There Any Data About Costs?
      • Conclusions and Comment
      • References
    • Chapter 26. Identifying Patients at Risk for Suicide: Brief Review (NEW)
      Steven C Bagley, MD.
      • Introduction
      • What Are the Practices for Reducing Inpatient Suicide?
      • How Have These Practices Been Implemented?
      • What Have We Learned About Practices for Reducing Inpatient Suicide?
      • What Methods Have Been Used To Improve Practices for Reducing Inpatient Suicide?
      • Conclusions and Comment
      • References
    • Chapter 27. Strategies To Prevent Stress-Related Gastrointestinal Bleeding (Stress Ulcer Prophylaxis): Brief Update Review
      Stephanie Rennke, MD, Robert M Wachter, MD, and Sumant R Ranji, MD.
      • Introduction
      • What Is Stress Ulcer Prophylaxis?
      • What Is the Context for the Use of Stress Ulcer Prophylaxis?
      • What Have We Learned About Stress Ulcer Prophylaxis?
      • Recent Reviews and Systematic Evaluations
      • No New Studies for Effectiveness of Acid Suppressive Therapy for Stress Ulcer Prophylaxis
      • PPI Use and Misuse Have the Potential for Harm
      • Costs and Implementation
      • Conclusions and Comment
      • References
    • Chapter 28. Prevention of Venous Thromboembolism: Brief Update Review
      Elliott R Haut, MD, FACS and Brandyn D Lau, MPH.
      • Introduction
      • What Are the Practices for Preventing Venous Thromboembolism?
      • What Approaches Have Been Used To Improve Appropriate VTE Prophylaxis?
      • What Have We Learned About These Practices?
      • Conclusions and Comment
      • References
    • Chapter 29. Preventing Patient Death or Serious Injury Associated With Radiation Exposure From Fluoroscopy and Computed Tomography: Brief Review (NEW)
      Nancy Sullivan, BA.
      • Introduction
      • What Are the Practices for Reducing Ionizing Radiation Exposure?
      • How Have These Practices Been Implemented?
      • What Have We Learned About These Practices?
      • Conclusions and Comment
      • References
    • Chapter 30. Ensuring Documentation of Patients' Preferences for Life-Sustaining Treatment: Brief Update Review
      Sydney Dy, MD, MSc.
      • Introduction
      • What Is the Practice of Ensuring Documentation of Life-Sustaining Treatment?
      • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
      • What Have We Learned About Documenting Life-Sustaining Treatments?
      • Conclusions and Comment
      • References
• Part 2b. Practices Designed To Improve Overall System/Multiple Targets
  • Chapter 31. Human Factors and Ergonomics
    Pascale Carayon, PhD, Anping Xie, MS, and Sarah Kianfar, MS.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs of the Patient Safety Practice?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 32. Promoting Engagement by Patients and Families To Reduce Adverse Events (NEW)
    Zack Berger, MD, PhD, Tabor Flickinger, MD, and Sydney Dy, MD, MSc.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 33. Promoting a Culture of Safety
    Sallie J Weaver, PhD, Sydney Dy, MD, MSc, Lisa H Lubomski, PhD, and Renee Wilson, MS.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 34. Effect of Nurse-to-Patient Staffing Ratios on Patient Morbidity and Mortality
    Paul G Shekelle, MD, PhD.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 35. Patient Safety Practices Targeted at Diagnostic Errors (NEW)
    Kathryn M McDonald, MM, Despina Contopoulos-Ioannidis, MD, Julia Lonhart, BS, BA, Brian Matesic, BS, Eric Schmidt, BA, Noelle Pineda, BA, and John PA Ioannidis, MD.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and In What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 36. Monitoring Patient Safety Problems (NEW)
    Fang Sun, MD, PhD.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 37. Interventions To Improve Care Transitions at Hospital Discharge (NEW)
    Stephanie Rennke, MD, Marwa H Shoeb, MD, MS, Oanh K Nguyen, MD, Yimdriuska Magan, BS, Robert M Wachter, MD, and Sumant R Ranji, MD.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 38. Use of Simulation Exercises in Patient Safety Efforts
    Eric M Schmidt, BA, Sara N Goldhaber-Fiebert, MD, Lawrence A Ho, MD, and Kathryn M McDonald, MM.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should This Patient Safety Practice Work?
    • What Are the Beneficial Effects of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented and in What Context?
    • Are There Any Data About Costs?
    • Are There Any Data About the Effect of Context on Effectiveness?
    • Conclusions and Comment
    • References
  • Chapter 39. Obtaining Informed Consent From Patients: Brief Update Review
    Kristina M Cordasco, MD, MPH, MSHS.
    • Introduction
    • What Is Informed Consent?
    • How Has Informed Consent Been Implemented?
    • What Have We Learned About Informed Consent?
    • What Methods Have Been Used To Improve Informed Consent?
    • Conclusions and Comment
    • References
  • Chapter 40. Team-Training in Health Care: Brief Update Review
    Sallie J Weaver, PhD and Michael A Rosen, PhD.
    • Introduction
    • What Is Team-Training?
    • What Is the Context for the Use of Team-Training?
    • What Have We Learned About Team-Training Effectiveness?
    • What Have We Learned About Team-Training Design and Delivery?
    • Conclusions and Comment
    • References
  • Chapter 41. Computerized Provider Order Entry With Clinical Decision Support Systems: Brief Update Review
    Sumant R Ranji, MD, Stephanie Rennke, MD, and Robert M Wachter, MD.
    • Introduction
    • What Are Computerized Provider Order Entry With Clinical Decision Support Systems?
    • How Have Computerized Provider Order Entry With Clinical Decision Support Systems Been Implemented?
    • What Have We Learned About Computerized Provider Order Entry and Clinical Decision Support Systems Since the “Making Health Care Safer Report?”
    • Conclusions and Comment
    • References
  • Chapter 42. Tubing Misconnections: Brief Review (NEW)
    Kelley Tipton, MPH.
    • How Important Is the Problem?
    • What Is the Patient Safety Practice?
    • Why Should the Patient Safety Practice Work?
    • What Are the Benefits of the Patient Safety Practice?
    • What Are the Harms of the Patient Safety Practice?
    • How Has the Patient Safety Practice Been Implemented, and in What Contexts?
    • Conclusions and Comments
    • References
  • Chapter 43. Limiting Individual Providers' Hours of Service: Brief Update Review
    Sumant R Ranji, MD and Robert M Wachter, MD.
    • Introduction
    • What Efforts Have Been Made To Reduce Clinician Work Hours?
    • What is the Context for Current Efforts To Reduce Work Hours?
    • What Have We Learned About Limiting Physician Work Hours?
    • Conclusions and Comment
    • References
• Part 3. Discussion
  • Chapter 44. Discussion
    • Introduction
    • Limitations
    • Conclusions
    • Future Research Needs
    • References
• Abbreviations/Acronyms
• Appendix A Original List of Patient Safety Practices
• Appendix B AMSTAR: A Measurement Tool To Assess Systematic Reviews
• Appendix C Literature Searches and Topic-Specific Methods
• Appendix D Supplementary Evidence Tables

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services¹, Contract No. 290-2007-10062-I. Prepared by: RAND Corporation, Santa Monica, CA, University of California, San Francisco/Stanford, San Francisco, CA, Johns Hopkins University, Baltimore, MD, ECRI Institute, Plymouth Meeting, PA

Suggested citation:

Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Report No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2013. www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

This report is based on research conducted by the Southern California-RAND Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10062-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

1

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