The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
McCleskey SG, Shek L, Grein J, et al. BMJ Qual Saf. 2022;31:308-321.
Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.
Haun N, Hooper-Lane C, Safdar N. Infection control and hospital epidemiology. 2016;37:1367-1373.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
Knobloch MJ, Thomas K, Musuuza J, et al. Am J Infect Control. 2019;47:633-637.
Health care–associated infections (HAIs) are a persistent challenge to patient safety. This review found that evidence regarding the role of leadership in implementing the Systems Engineering Initiative for Patient Safety framework to HAI reduction was limited. The authors conclude that research is needed to examine how communication and leadership characteristics affect work system approaches to HAI prevention.
Leback C, Johnson DH, Anderson L, et al. Infect Control Hosp Epidemiol. 2018;39:841-848.
This direct observation and interview study identified barriers to and facilitators of safe injection practices in outpatient care. Inadequate time and staffing inhibited safe injection practices. The availability of safety needles and prefilled syringes improved the use of safe practices. The authors note that knowledge of safe injection practices does not ensure sufficient implementation.
McClung L, Obasi C, Knobloch MJ, et al. Am J Infect Control. 2017;45:1064-1068.
Preventing health care–associated infections is a patient safety priority. This interview study found that health care workers are highly motivated to prevent health care–associated infections to foster patient safety, and they believe leadership support and performance feedback are important to infection prevention efforts.
Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.
Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.
Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.
Prompt removal of intravenous catheters is critical to preventing health care–associated infections. This systematic review found that persistence of idle, or unused, catheters was associated with adverse outcomes. These findings highlight the need to develop and implement practices to reduce the incidence of idle catheters.
Meddings J, Reichert H, Greene T, et al. BMJ Qual Saf. 2017;26:226-235.
Programs to prevent health care–associated infections (HAIs) have been some of the most prominent successes of the patient safety movement. These programs—including the Keystone ICU program and a recent effort to prevent catheter-associated urinary tract infections—have emphasized improving safety culture along with specific technical interventions. Analyzing data from two AHRQ-funded programs to prevent HAIs, this study sought to examine the relationship between Hospital Survey on Patient Safety Culture scores and HAI rates. Interestingly, no association was found between safety culture scores and HAI rates at the hospital unit level, even though HAI rates consistently improved during the study period. The authors note two possible interpretations of these results: first, safety culture may not be a crucial component of programs to reduce HAIs; second, survey results may not be an accurate measure of safety culture (especially in this study, where survey response rates were low). Other studies have indicated a stronger relationship between safety culture and rates of other types of adverse events. Therefore, despite this study's results, establishing a safety culture remains important.
Musuuza JS, Barker A, Ngam C, et al. Infect Control Hosp Epidemiol. 2016;37:567-75.
This systematic review of hand hygiene interventions revealed that only 8 of 100 studies documented the extent to which the planned intervention was implemented. It is critical to routinely examine implementation metrics because proven patient safety practices are often not effective when tried in new settings.
Nuckols TK, Asch SM, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:341-350.
Although computerized physician order entry (CPOE) with decision support is considered to be integral to patient safety, high implementation costs and unintended consequences have led to mixed reactions. This cost-utility analysis compared CPOE with paper ordering among patients in acute care hospitals and concluded that CPOE would yield cost savings and improve health outcomes by reducing preventable adverse drug events. The authors noted that high implementation costs, which often exceed prior estimates, significantly decreased the projected cost savings. A related editorial suggests these findings argue conclusively for universal CPOE with decision support, despite the short-term challenges of implementation.