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Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Rockville, MD: Agency for Healthcare Research and Quality; September 2020.

Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living conditions, and nursing home staff are among the most at-risk essential workers. In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established this network to prevent infections among nursing home residents and staff. All nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program that includes peer-to-peer, case-based learning and additional mentorship from local and national experts. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics. 

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Circle Up for COVID-19 Training. Center for Medical Simulation.

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
QualityNet. Centers for Medicare and Medicaid Services.
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.
Peggy Lillis Foundation; PLF.
Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots foundation employs educational, policy, and advocacy strategies aimed at reducing C. difficile infections. The website provides information for patients, families, health care providers, and advocates. The foundation hosts an annual C. difficile awareness campaign in November.
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program provides educational webinars and implementation guidance to help hospitals use an AHRQ toolkit to decrease risk of falls. The toolkit draws from a 2-year pilot project that achieved sustained improvements for organizations in the program.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017.
Health literacy is important for effective care communications and safe medication use. This toolkit provides resources associated with medication therapy management and patient health literacy. Materials include health literacy assessments and guidance for prescription medicine instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.

1212 Avenue of the Americas, 5th Floor, New York, NY 10036. 212-244-6294 contact@endsepsis.org

Sepsis is a serious condition that can be rapidly fatal if it is not promptly diagnosed and treated. This website and the Rory Staunton Foundation for Sepsis Prevention seeks to improve education and awareness of sepsis in the name of a pediatric patient who died when his sepsis was misdiagnosed in the emergency room.
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.
Center for Health Design.
Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.
Joint Commission. Oakbrook Terrace, IL: Joint Commission; 2014.
Safety problems, particularly medication errors and poor hand hygiene compliance, are common in nursing homes. This Web site offers an online learning module and related information about how to apply high reliability concepts to reduce health care–associated infections in long-term care settings.
Health Quality & Safety Commission New Zealand.
This Web site hosts tools and resources associated with a national campaign to augment patient care. The initiative aims to build collaborative programs across New Zealand to reduce falls, health care–associated infections, medication errors, and harm related to surgery.
Global Sepsis Alliance.
This website provides resources to raise awareness of sepsis, including information about its increasing incidence and causes for its delayed diagnosis. World Sepsis Day occurs yearly on September 13th.