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A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes

Manojlovich, Milisa PhD, RN, CCRN; Lee, Soohee MSN; Lauseng, Deborah AMLS

doi: 10.1097/PTS.0000000000000093
Review Article

This is a systematic review of the literature on unintended consequences of clinical interventions to reduce falls, catheter-related urinary tract infection, and vascular catheter-related infections in hospitalized patients. A systematic search of the literature was conducted in CINAHL and PubMed. We developed a screening tool and a two-stage screening process to identify relevant articles. Nine articles met inclusion criteria, and of those, 8 reported on interventions to reduce patient falls. Four studies reported a positive, unexpected benefit; 3 studies reported a negative, unexpected detriment; and 4 reported a perverse effect (different from what was expected). Three studies reported both positive and perverse effects arising from the intervention. In 4 of the studies, despite fall prevention interventions, patients fell while trying to get to the bathroom, suggesting that interventions to reduce one adverse outcome (i.e., CAUTI) may be associated with another outcome (i.e., patient falls). In some cases, there were positive outcomes for those who implemented and/or evaluated interventions. We encourage colleagues to collect and report data on possible unintended consequences of their interventions to allow a fuller picture of the relationship between intervention and all outcomes to emerge.

From the *University of Michigan School of Nursing; and †University of Michigan Taubman Health Sciences Library Ann Arbor, Michigan.

Correspondence: Milisa Manojlovich, PhD, RN, CCRN, University of Michigan School of Nursing, 400 N. Ingalls, Room 4306, Ann Arbor, MI 48109 (e-mail:

Funding: Funding for this project was provided by the 2012 Rackham Spring/Summer Research Grants Program, at the University of Michigan.

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