The PSNet Collection

Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication.

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Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

COVID-19 Focused Inspection Initiative in Healthcare.

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Occupational Safety and Health Administration. March 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

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Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

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Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus Prevention. Request for Proposal Comment.

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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.

Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine.

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Fed Register. 2021;86(51):14752-14753.

The Patient Safety and Quality Improvement Act of 2005 created a framework that supports efforts to improve patient safety and reduce the incidence of adverse events. It also requires the Secretary of the U.S. Department of Health and Human Services, in consultation with the Director of the Agency for Healthcare Research and Quality, to prepare a draft report on effective strategies for improving patient safety and encouraging the use of effective improvement strategies. The deadline for public comment on the draft report has now passed.

Using ventilator splitters during the COVID-19 pandemic--letter to health care providers.

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Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021.

Lack of access to ventilators during the COVID-19 crisis has necessitated care compromises to support multiple patients. This situation can reduce the effectiveness of monitoring patients on shared devices and introduce other challenges. This communication provides insights to enhance the safety of multiple-patient ventilator use.

Wear face masks with no metal during MRI exams.

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FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.

Northeastern University Hospital Surge Capacity Planning Model: Bed, Ventilator, and PPE 1-30 Day Demand.

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Rockville, MD; Agency for Healthcare Research and Quality: 2020.

The COVID-19 pandemic is placing surge demand and strain on health organizational, department, and unit-level capacity and personnel. This announcement features a prototype tool as a model for health systems to evaluate hospital-specific demand for medical and intensive care unit beds and the needed equipment to equip staff to keep patients safe during shifting conditions associated with providing care during an emerging crisis.

Joint Statement on Multiple Patients Per Ventilator.

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The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, American Association of Critical‐Care Nurses, AACN, and American College of Chest Physicians. March 26, 2020.

Innovations must be incorporated into care processes with safety in mind. This announcement shares insights to mitigate strategies that may cause patient harm through alternative use of ventilators to support multiple patients with compromised respiratory function.

Infections associated with reprocessed flexible bronchoscopes.

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FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.

Use of incompletely cleaned medical devices has been linked to health care–associated infections. Drawing from reports submitted to the FDA regarding infections related to reprocessed flexible bronchoscopes, this announcement offers recommendations to enhance the reliability of scope sterilization methods.

FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients.

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FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.

The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.

Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.

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Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH.

This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

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Joint Commission.

This announcement reveals the new National Patient Safety Goal for 2012, which aims to reduce catheter-acquired infections in hospitals. Note: This alert has been retired effective January 1, 2020.

Announcing 2009 Leapfrog top hospitals.

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Washington, DC: Leapfrog Group; December 4, 2009.

This news announcement highlights the 45 urban, children's, and rural hospitals recognized for highly efficient performance and continuous improvement in patient safety based on the 2009 Leapfrog Hospital Survey results.

Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens.

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FDA Alert. Silver Spring, MD; US Food and Drug Administration: March 19, 2009.

This announcement alerts clinicians and patients that insulin pens and insulin cartridges are never to be used on more than one patient.

10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs.

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AHRQ; Agency for Healthcare Research and Quality.

This announcement highlights a program in 10 states that will test methods of reducing central-line–associated blood stream infections in hospital intensive care units.

The MacArthur Fellows Program: Peter Pronovost.

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The John D. and Catherine T. MacArthur Foundation.

Through his work, Peter Pronovost, a critical care physician and professor at Johns Hopkins University School of Medicine, has inspired culture change by devising evidence-based clinical practices that save lives and improve patient safety. The MacArthur Foundation has selected him as a 2008 Fellow and recipient of a $500,000 "genius grant."

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