All Content

Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.

Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Hospitals employ a variety of strategies to prevent inpatient falls. Based on data from incident reports, this study used process mapping to identify opportunities to improve timely diagnosis of serious injury resulting from inpatient falls. Researchers found that multiple interventions (e.g., education, changes in the transport process) with small individual effects resulted in a substantial cumulative positive impact on delays in the diagnosis of serious harm resulting from a fall.

Changes in healthcare delivery and care processes as a result of the COVID-19 pandemic have increased the risk for falls. This study explored the impact of the COVID-19 pandemic and the implementation of a fall prevention program (focused on human factors and ergonomics principles) on inpatient fall rates at one hospital in Hong Kong. Findings indicate that fall rates significantly increased from pre-COVID to during the first wave of the pandemic (July-June 2020). The fall prevention program – implemented in July 2020 – led to a reduction of fall rates, but not to pre-pandemic levels.

Diagnostic error and misdiagnosis of stroke patients can lead to preventable adverse events, such as treatment delays and adverse outcomes. Researchers at a Swiss hospital retrospective reviewed patients admitted for transient ischemic attack (TIA) or ischemic stroke and found that a trigger tool could accurately identify preventable events among patients with adverse events and no-harm incidents. The most common preventable events were medication events, pressure injuries, and healthcare-associated infections.

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.

Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).

Maternal morbidity and mortality remains a major public health concern, particularly among pregnant people of color. This US hospital established a multi-disciplinary committee, the obstetric Quality and Peer Review Committee (OBQPRC), to review all cases of severe maternal morbidity (SMM). This article compares the pre- and post-intervention periods to determine if rates of potentially preventable SMM decreased. While there was no difference in SMM rates pre- and post-intervention, the rate of potentially preventable events significantly decreased after implementation of routine review of all SMM.  

According to an Agency for Healthcare Research and Quality study, an estimated 700,000 to 1 million hospitalized patients fall each year. This study assessed the impact of potentially inappropriate medications (PIM) on falls in older adults and compared the impact of three deprescribing tools on inpatient falls. PIMs identified by section K of the Screening Tool of Older Persons' Prescriptions (STOPP) had the strongest association with inpatient falls.

Safety bundles are known to improve clinician adherence to guidelines and improve patient safety. This children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant deaths. Overall compliance with safe sleep guidelines increased from 9% to 72%. Three individual components also improved (head of bed flat, sleep space free of extra items, and caregiver education completed); one measure, centerline for infant in supine position, remained stable. The safe sleep bundle was shown to be effective in improving infant sleep environments.

Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.

Improving maternal safety is a priority patient safety issue. Using the Global Trigger Tool, researchers found that nearly three-quarters of adverse events in one labor ward in a Swedish hospital were preventable. Common events included lacerations and anesthesia-related events and often resulted in a prolonged hospital stay.