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PSNet: Patient Safety Network
Journal Article
Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene T, Meddings J, et al. JAMA internal medicine. 2017;177:1154-1162.

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.