… cancer surgeries. The program was associated with a significant reduction in surgical site infections and an …

… Care … Using ventilator-associated adverse events as a test case, this study illustrates how the public–private … of patient safety issues. The group successfully developed a common taxonomy for evaluating adverse events from three …

… of events. In this study, researchers tested a concise incident analysis method, drawing on multiple … use it beyond the pilot phase. These results suggest that a more streamlined method of investigating adverse events …

… each separate aspect of safety climate is linked to a particular safety problem. …

This commentary describes a World Health Organization effort to design and apply standardized care processes to address safety concerns. Three standards (surgical site identification, medication reconciliation, and concentrated injectable medicines) have been developed and implemented in multiple countries in the past 5 years.

Incident reporting systems are a popular method for hospitals to detect patient safety hazards. This review highlights limitations and strengths of incident reporting in safety improvement programs and makes recommendations to enhance their usefulness, including prioritizing and examining incidents to identify which events occur more often or lead to more harm.

This commentary describes a four-element framework to track progress of safety improvement in the emergency department.

… can be nearly eliminated through implementation of a safety bundle . Prior studies have argued that these … savings in hospital costs by avoiding CLABSI, but it finds a concomitant marked decrease in hospital reimbursement … rates. Under the fee-for-service system, hospitals net a margin of approximately $55,000 for patients that develop …

This commentary discusses barriers to understanding and measuring progress in safety improvement and describes seven priorities to guide development of patient safety measures.

Rapid response systems (RRSs) are somewhat effective at preventing cardiorespiratory arrest outside the intensive care unit, according to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal Medicine. The review also identifies barriers and facilitators to effective implementation of RRSs in different contexts.

As a result of the landmark Keystone ICU project, central line–associated bloodstream infections (CLABSIs) have emerged as a flagship patient safety target in recent years. The national Comprehensive Unit-Based Safety Program (CUSP) initiative aims to further disseminate these results by creating state-level cohort collaboratives. This current report of the initiative's implementation and sustainability in Hawaii continues the project's encouraging results, with CLABSI rates significantly decreased across the entire state. Most notably, Hawaii has successfully spread this program beyond adult intensive care units (ICUs) into pediatric and neonatal ICUs, and even non-ICU wards. The article outlines specific innovative tools and strategies utilized by the Hawaii collaborative, with an emphasis on cultural change and establishing new local norms. An AHRQ-sponsored CUSP toolkit is freely available.

This article provides an overview on numerous types of medical errors and adverse events, describing their impact, contributing factors, and strategies to address them.

… reporting and root cause analysis . This commentary draws a contrast between this approach and that used in the nuclear … focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power … by an independent non-regulatory body, which conducts a detailed safety assessment and makes specific …

This commentary describes an application used to translate performance-related data into performance estimates to help prevent central line–associated bloodstream infections.

Building on the success of the landmark Keystone ICU project, this study demonstrated that a similar intervention could nearly eliminate central line–associated bloodstream infections throughout Hawaii.

A convincing body of literature demonstrates that adequate nurse staffing improves patient safety. However, achieving an appropriate nurse-to-patient ratio may necessitate using temporary staff, who may themselves be a source of error due to being unfamiliar with the care environment. This analysis of national MEDMARX data found that medication errors committed by temporary staff, primarily nurses, were more likely to cause patient harm than errors committed by regular staff. Although the findings may represent reporting bias, since MEDMARX consists of voluntarily reported data, prior studies have also demonstrated that high levels of temporary staff may pose patient safety risks.

A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.

This study found that reducing errors associated with medical devices/equipment in the operating room (OR) was a key opportunity for error prevention, whereas medication safety was a focus for prevention outside the OR.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.