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Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.

This study examined the association of inpatient harms (e.g., infections, medication-related harms) and 30-day readmissions through a retrospective analysis of adult surgical patients in a single heath system over a two year period. The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%), central line-associated bloodstream infections (40%), Clostridium difficile infections (29%), international normalized ratio >5 for patients taking Warfarin (26%), and catheter-associated urinary tract infections. The authors also described the accuracy of a risk prediction model to identify high-risk patients for 30-day admissions.  

Intubation occurring outside the operating room (OR) is rare but associated with life-threatening adverse events. This review provides an overview of situational, physiological and anatomical contributors to intubation of children outside of ORs; situational challenges – such as human factors or unfamiliar equipment – are most common. Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed, such as systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, multi‐disciplinary team engagement and training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance.

Checklists allow health care teams to adhere to best practices. In a single institution's pediatric intensive care unit, a quality champion who prompted teams to discuss a safety checklist daily facilitated a reduction in urinary catheter days and length of stay. However, the patients cared for during the quality champion's tenure had lower illness severity.

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.

The Swiss cheese model illustrates how independent weaknesses can combine to result in failure. This commentary examines factors that contribute to central venous catheterization mistakes and applies the Fishbone diagram to show areas requiring process improvement. The authors suggest steps before, during, and after central venous catheter placement to support safe practice.

This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.

This retrospective review examines incidents of retained guidewires reported to The Joint Commission. Researchers identified numerous contributing factors to these events, most frequently relating to human factors, leadership, and communication. The authors conclude that multicomponent strategies to prevent incidents involving retained foreign objects are needed.

The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.

This study reviewed mandatory reporting of patient-controlled analgesia device-related events to the Food and Drug Administration postmarketing surveillance database. Less that 10% of reported events were deemed adverse events, and the vast majority of these were preventable. The authors call for development and adoption of patient-controlled analgesia devices with improved safety features and better training.