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Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Bach TA, Berglund L-M, Turk E. BMJ Open Qual. 2018;7:e000202.
Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.
Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-15.
This study reports the initial findings from a voluntary, Web-based patient safety incident reporting system for intensive care units (ICUs). The system, developed through funding by the Agency for Healthcare Research and Quality (AHRQ), collected data on incidents that could have resulted in patient harm. During the study, more than 2000 reports were filed from 23 participating ICUs. A substantial minority (42%) of incidents led to patient harm, and most had multiple contributing factors, such as deficiencies in training or teamwork. The authors note that the science of incident reporting systems is still in its infancy and recommend that future research should study how to use incident reporting data to improve patient safety.
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.