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AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.

Problems in communication are common contributors to patient care mistakes. This toolkit draws from experience with the TeamSTEPPS model to highlight best practices in the use of huddles, debriefs and other teamwork improvement strategies.

Centers for Disease Control and Prevention.

Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This US Centers for Disease Control and Prevention (CDC) initiative provides access to science, CDC actions, and expert insights on the value of public health efforts to reduce the impact of systemic racism on health in the United States.
Czeisler MÉ, Marynak K, Clarke KEN, et al. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257.
This nationwide survey of U.S. adults found that many respondents (40.9%) have avoided routine, urgent and emergent medical care during the COVID-19 pandemic. Avoidance of urgent or emergency care was significantly higher among unpaid caregivers for adults; persons with underlying medical conditions; persons with health insurance; non-Hispanic Black, Hispanic, or Latino adults; young adults; and persons with disabilities.
Dora AV, Winnett A, Jatt LP, et al. MMWR Morb Mortal Wkly Rep. 2020;69(21):651-655.
This report describes an outbreak of COVID-19 among residents at one skilled nursing facility in Los Angeles between March 28 and April 23, 2020 and highlights the high asymptomatic prevalence of COVID-19 and unique risk to residents and staff at long-term care facilities. Authors emphasize that universal and serial RT-PCR testing, rapid isolation, and cohorting can disrupt transmission of the SARS-CoV-2 virus.
Petersen EE, Davis NL, Goodman D, et al. MMWR. Morbidity and mortality weekly report. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Scholl L, Seth P, Kariisa M, et al. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
Meyer AND, Thompson PJ, Khanna A, et al. J Am Med Inform Assoc. 2018;25:841-847.
Clinical decision support is a widely recommended patient safety strategy. This study examined whether a mobile application created by the Centers for Disease Control and Prevention improved clinician decision-making about anticoagulation test ordering for simulated case vignettes. Each participating physician completed a series of vignettes; half used the application and half did not. When using the application, physicians demonstrated greater diagnostic accuracy and confidence, and they needed less time to complete each vignette. The authors suggest that mobile applications may be useful for providing decision support.
Kossover-Smith RA, Coutts K, Hatfield KM, et al. American journal of infection control. 2017;45:1018-1023.
Unsafe injection practices in health care settings have led to more than 50 disease outbreaks in the past 20 years. In this cross-sectional, voluntary survey across 8 states, 12% of responding physicians stated that needles were reused between patients in their workplace. Nearly 8% of physicians thought this was an acceptable practice. The authors discuss implications for the Center for Disease Control and Prevention's One & Only safe injection campaign.
Centers for Disease Control and Prevention; CDC.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.
Patel PR, Brinsley-Rainisch K. Clinical Journal of the American Society of Nephrology. 2017;13.
Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a collective effort that aims to develop, share, and test a set of interventions and tools to ensure the safety of dialysis.
Harvey AR, Basavaraju SV, Chung K-W, et al. Transfusion. 2014;55.
Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surgery. 2017;152.
Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.
Rudd RA, Seth P, David F, et al. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452.
Opioid medications are frequently associated with adverse drug events in inpatient and outpatient settings. This surveillance report from the Centers for Disease Control and Prevention demonstrated that the magnitude of patient harm from opioid use is growing rapidly. Opioid overdose deaths are increasing each year, through 2015, and current rates are the highest ever recorded. The types of opioids most commonly involved in overdose deaths are natural and semisynthetic opioids, which are often prescribed as pain relievers. The authors suggest that the adoption of new prescribing guidelines and more widespread use of the opioid reversal agent naloxone will help address this growing epidemic. An earlier version of this article included data through 2014. A previous WebM&M commentary described a fatal opioid overdose.
Dowell D, Zhang K, Noonan RK, et al. Health affairs (Project Hope). 2016;35:1876-1883.
Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.
Novosad SA, Sapiano MRP, Grigg C, et al. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869.
Sepsis has been a significant focus of quality improvement initiatives. In this retrospective review, researchers sought to identify patient characteristics, risk factors, and infections that might inform sepsis diagnosis, treatment, and prevention efforts. The medical records of a random sample of 246 adult and 79 pediatric patients with codes for severe sepsis or septic shock across 4 New York hospitals were reviewed. Investigators found that 72% of patients had exposure to at least one health care factor during the 30 days prior to being admitted for sepsis or a medical condition requiring frequent health care contact. Pneumonia was the most frequently documented infection causing sepsis. They concluded that reducing sepsis will require an ongoing focus on infection prevention.
CDC; Centers for Disease Control and Prevention.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Centers for Disease Control and Prevention.
Concerns about patient harm from prescription opioid misuse are increasing in the United States. This website provides guidelines for use of opioid medications and information to raise awareness about the need to improve physicians' prescribing decisions and patients' medication use.
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.
Opioid pain medications carry high risk for adverse drug events and misuse. Due to climbing rates of opioid use and associated adverse events, the Centers for Disease Control and Prevention released new guidelines for prescribing opioid medications for chronic pain. These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life care. The authors recommend using opioids for chronic pain only if nonopioid medications and nonpharmacologic approaches to chronic pain are not effective and prescribing immediate-release instead of long-acting medications. For acute pain, they recommend limiting duration of therapy, stating that more than 1 week of medications should rarely be needed. The guidelines also suggest minimizing concurrent use of opioids and other sedating medications and dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids.