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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.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.

Katz MJ, Tamma PD, Cosgrove SE, et al. JAMA Netw Open. 2022;5(2):e220181.

Overuse of antibiotics has been common in nursing homes; therefore, antibiotic stewardship programs (ASPs) have been emphasized by experts. To assist facilities, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use developed programs and a toolkit to improve the appropriate use of antibiotics. This quality improvement program found that a focused educational initiative to establish ASPs in nursing homes was associated with reduction in antibiotic use in those facilities with high levels of engagement.

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.

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 intensive care units and acute care is currently recruiting participants. Cohorts devoted to surgical services and long-term care will begin enrolling members later in 2022.
Evans S, Green A, Roberson A, et al. J Pediatr Nurs. 2021;61:151-156.
A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU). The framework included both objective and subjective criteria. By identifying patients at increased risk of clinical deterioration (“watcher status”) and use of the framework, recognition of deterioration occurred sooner and resulted in fewer emergency transfers to the ICU.
Mitchell OJL, Neefe S, Ginestra JC, et al. Resusc Plus. 2021;6:100135.
Rapid response teams (RRT) are intended to improve the identification and management of clinically worsening hospitalized patients. This study identified an increase in RRT activations for respiratory distress at one academic hospital during the COVID-19 pandemic. The authors outline the hospital response, which included revising RRT guidelines to reduce in-room personnel, new decision-support pathways, which accounted for COVID-19 uncertainty, and expanded critical care consults for inpatient care team.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.

This notice announces a call for comments on an information collection project drawing from the Comprehensive Unit-based Safety Program (CUSP). This project will support the implementation of targeted hospital-acquired infection improvement initiatives in intensive care units, long term care and surgical environments to reduce the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). The process for submitting comments is now closed.
Danielis M, Destrebecq A, Terzoni S, et al. Dimens Crit Care Nurs. 2021;40:186-191.
While the effectiveness of medical emergency teams (MET) has been widely researched, critical incidents that occur during the response have not received the same attention. This retrospective study analyzed critical incidents that occurred during MET responses over a five-year period. They mainly occurred due to lack of compliance with protocols and lack of available supplies. Educational and organizational strategies may be effective in reducing critical events during MET.
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;34:580-586.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;30:697-705.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
O’Neill SM, Clyne B, Bell M, et al. BMC Emerg Med. 2021;21:15.
Early warning systems (EWS) can aid in early detection of clinical deterioration and assist rapid response teams (RRTs). In this qualitative synthesis, the authors identified barriers and facilitators to the escalation of care according to early warning system protocols. The overarching themes involved governance (e.g., standardization, resources), RRT behaviors, professional boundaries, clinical experience, and EWS parameters.
Kanaan AO, Sullivan KM, Seed SM, et al. Pharmacy (Basel). 2020;8:225.
The COVID-19 pandemic has affected the ability of pharmacists to ensure medication safety. This article uses case scenarios to highlight challenges encountered due to the COVID-19 pandemic that required changes in pharmacist roles. Strategies to overcome challenges related to monitoring medications used to treat patients with COVID-19, preventing errors with laboratory reporting, and managing drug shortages are discussed.
Naseralallah LM, Hussain TA, Jaam M, et al. Int J Clin Pharm. 2020;42:979-994.
Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessio

J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   

Stanford, CA; California Maternal Quality Care Collaborative: January 22, 2020. 

This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.