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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.

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

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.
Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.
Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.
McCleskey SG, Shek L, Grein J, et al. BMJ Qual Saf. 2022;31:308-321.
Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.
Forrester JD, Maggio PM, Tennakoon L. J Patient Saf. 2022;18:e477-e479.
Healthcare-associated infections (HAIs) result in poorer patient outcomes and increased costs. The 2016 national data set of five common HAIs (surgical site infections, catheter- and line-associated bloodstream infections, catheter-associate urinary tract infections, ventilator-associated pneumonia, and Clostridioides difficile) was analyzed to create an estimated national cost. Clostridioides difficile was the most frequently reported; Clostridioides difficile and surgical site infections accounted for 79% of costs.
Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.
The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.
Fakih MG, Bufalino A, Sturm L, et al. Infect Control Hosp Epidemiol. 2021;43:26-31.
Central line-associated blood steam infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) prevention were an important part of patient safety prior to the COVID-19 pandemic. This study compared CLABSI and CAUTI rates in 78 hospitals during the 12-month period prior to the pandemic and the first 6 months of the pandemic. CLABSI rates increased by 51% during the pandemic period, mainly in the ICU. CAUTI rates did not show significant changes.
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. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.

Tubing misconnections have been associated with medication administration errors, and yet, design strategies to minimize these mistakes are only beginning to be uniformly implemented. This article shares the story of a contrast media administration error associated with communication and handoff errors. The piece recommends focusing on universal design standards to improve administration along with clinical steps to mitigate the potential for this type of error.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
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.
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
Kandagatla P, Su W-TK, Adrianto I, et al. J Healthc Qual. 2021;43:101-109.
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.  
Long E, Barrett MJ, Peters C, et al. Pediatric Anesthesia. 2020;30.
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.
Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of Medicine at the University of Michigan Medical School. His research focuses on improving the safety of hospitalized patients by preventing hospital-acquired complications—particularly those associated with peripherally inserted central catheters.
Cifra CL, Houston M, Otto A, et al. Jt Comm J Qual Patient Saf. 2019;45:543-551.
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.
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.
Thonon H, Espeel F, Frederic F, et al. Acta Clin Belg. 2020;75:193-199.
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.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
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.