Creating high reliability in health care organizations.
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
(eg, the aviation industry) have developed methods for achieving safety despite hazardous conditions. This study describes the development of a framework to achieve high reliability in the intensive care unit (ICU) context and discusses its application to the problem of preventing catheter-related bloodstream infections. The framework is based on a
method for evaluating safety interventions; the key elements include selecting measurable outcomes, applying evidence-based interventions, ensuring the intervention reaches all patients, and improving the overall
culture of safety
. The investigators applied this approach in ICUs in Michigan and achieved significant reductions in the incidence of catheter-related bloodstream infections.
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Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia: [L'observation de mesures simples et efficaces reduit l'incidence de pneumonie associee a la ventilation mecanique].
Baxter AD, Allan J, Bedard J, et al. Can J Anaesth. 2005;52:535-541.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the Prevention Epicenter Program.
Warren DK, Yokoe DS, Climo MW, et al. Infect Control Hosp Epidemiol. 2006;27:8-13.
Tubing misconnections—a persistent and potentially deadly occurrence.
Sentinel Event Alert. April 3, 2006;(36):1-3.
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