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National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. Letters of intent are due November 2, 2022.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

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.

Grimm CA. Washington DC: Office of the Inspector General; May 2022. Report no. OEI-06-18-00400.

In its 2010 report, the Office of the Inspector General (OIG) found 13.5% of hospitalized Medicare patients experience harm in October 2008. This OIG report has updated the proportion of hospitalized Medicare patients who experienced harm and the resulting costs in October of 2018. Researchers found 12% of patients experienced adverse events, and an additional 13% experienced temporary harm. Reviewers determined 43% of harm events could have been prevented and resulted in significant costs to Medicare and patients.

Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.

Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

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.
World Health Organization
This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative includes an annual promotional campaign that takes place on May 5. The theme for 2022 is "Unite for Safety".

Occupational Safety and Health AdministrationMarch 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. This project will support the implementation of targeted hospital-acquired infection prevention initiatives building on the Comprehensive Unit-based Safety Program (CUSP) concept. The cohort that is focused on surgical services is currently recruiting participants. A cohort devoted to long-term care will begin enrolling members later in 2022.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Trenton, NJ: New Jersey Department of Health and Senior Services.
Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.
Atlanta, GA: Centers for Disease Control and Prevention; October 2021.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2020 revealed increases in central line–associated bloodstream infections and other infections while a decrease in surgical site infections. The current report also discusses the impact of COVID-19 on reporting and data submission efforts.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.
Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through May 27, 2025.