Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.

The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  

… physicians. … Catalanotti JS, O'Connor AB, Kisielewski M, et al. Barriers to accessing nighttime supervisors: a …

… and employed debiasing strategies . … Gupta A, Quinn M, Saint S, et al. How physicians think: a case-based …

… harm, and potential harms of zero-harm initiatives (e.g., misclassifying preventable events, failing to consider opportunity costs).   … Meddings J, Saint S, Lilford R, et al. Targeting zero harm: a stretch goal that risks …

… reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask …

… clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners …

This educational intervention used a comic book format to convey patient safety concepts to internal medicine residents. Awareness and confidence in patient safety topics including medication safety and fall prevention improved on the post-test compared to the pre-test, suggesting this modality has promise as a patient safety education tool.

This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.

This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.

The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.

This ethnographic study examined the process of making a diagnosis among academic inpatient medical teams. Investigators observed that diagnosis requires dialogue within team, needed data is often not available, and distractions and time pressure are frequent. These observations may inform future interventions to improve timeliness and accuracy of diagnosis.

Communication errors during handoffs can lead to patient harm. Standardizing the handoff process has been shown to improve patient safety. This prospective trial demonstrated that implementation of a standardized intensive care unit sign-out process among residents led to fewer unexpected patient events and unplanned interventions.

Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.

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.

Reliance on information technology has surfaced a myriad of unintended consequences. This commentary highlights the importance of the physician–patient encounter and how such interactions have diminished with the implementation of electronic health records. The authors caution against the downsides of heuristics, cognitive errors, and implicit bias during the initial exam and underscore the value of contextual information gathered from personal interaction.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.

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.