Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.

In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.

… used as a measure to reward quality of care. … Klompas M, Platt R. Ventilator-associated pneumonia--the wrong quality …

This randomized study found that academic detailing yielded modest impact on appropriate monitoring of patients started on selected high-risk medications. A past study also demonstrated limited success with academic detailing as a sole intervention to promote medication safety.

In this AHRQ-funded study, the researchers found that decision support improved prescribing behavior in accordance with the evidence for common pediatric outpatient conditions.

The authors propose an approach to simulation training that combines simulated patients (actors) with high-fidelity technology for a more authentic clinical experience.

This study demonstrated that replacing drug-specific alerts with age-specific ones sustained (but did not enhance) previously noted decreases in inappropriate prescribing with drug-specific alerts alone. Investigators conducted a cluster-randomized trial of seven practices that received age-specific alerts in addition to academic detailing with eight practices that received only the alerts. The academic detailing process involved an interactive educational program to assist with alternative and evidence-based medication choices. Findings suggested that clinical decision support can be effective using alert systems, but improvements in tools such as academic detailing are needed, as the process had no benefit in this study. Shifting to age-specific alerts did decrease the alert burden overall to providers. A past review discussed the issue of inappropriate prescribing in the elderly while other studies evaluated its prevalence in outpatient settings and elderly veterans.

The authors evaluated the effectiveness of computerized alerts in reducing co-prescribing of warfarin and interacting medications. They found that the alerts had a modest impact on minimizing this potentially dangerous behavior.

This AHRQ–funded study discovered that the use of alerts within an electronic medical record system can reduce the number of unsafe medications prescribed in elderly outpatients. Investigators evaluated the impact of a clinical decision support system (CDSS) at the point of computerized provider order entry (CPOE), targeting two classes of contraindicated medications (long-acting benzodiazepines and tertiary amine tricyclic antidepressants). The authors discuss the rapid, significant, and persistent reductions in medication prescribing of these high-risk medications, suggesting the effectiveness of an alert system to curtail inappropriate prescribing. This study is a first to evaluate a computerized alert system in a large population-based primary care setting, although a past systematic review evaluated the effects of CDSS on practitioner performance and patient outcomes.

The authors argue for the development of universal measures for monitoring adverse events.

The authors of this AHRQ–funded study counted overdoses and underdoses in new prescriptions and found that 15% of pediatric outpatients received orders containing potential dosing errors.

… carried a potential for serious harm, classified by an FDA black box warning (BBW). Using a retrospective method to …

Given a lack of effective systems to detect adverse events with new vaccine administration, this study used existing data to compare event rates after changing to new rotavirus and diphtheria-pertussis-tetanus (DPT) vaccines. The surveillance system accurately captured adverse events, which supports the viability of similar systems in monitoring new vaccine safety.