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Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;Epub May 2.
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.

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.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;Epub Apr 5.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

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.
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

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.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Alboksmaty A, Beaney T, Elkin S, et al. The Lancet Digital Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Tham N, Fazio T, Johnson D, et al. World J Surg. 2022;46:1249-1258.
The COVID-19 pandemic led to changes in infection control and prevention measures to limit nosocomial spread. This retrospective cohort study found that escalations in infection prevention and control practices due to the COVID-19 pandemic did not affect the incidence of other hospital-acquired infections among surgical patients at one Australian hospital. The authors posit that this may be due to high compliance with existing infection prevention and control practices pre-pandemic.
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.
Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.
Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.
O’Brien N, Shaw A, Flott K, et al. J Glob Health. 2022;12:04018.
Improving patient safety is a global goal. This literature review explored patient safety interventions focused on people living in fragile, conflict-affected, and vulnerable settings. Studies were generally from lower and lower-middle income countries and focused primarily on strengthening infection prevention and control; however, there is a call for more attention on providing patient safety training to healthcare workers, introducing risk management tools, and reducing preventable harm during care delivery.
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.
World Health Organization
This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative includes an annual promotional campaign that takes place on May 5. The theme for 2022 is "Unite for Safety".

Occupational Safety and Health AdministrationMarch 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.
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.
Yesmin T, Carter MW, Gladman AS. BMC Health Serv Res. 2022;22:278.
Advanced technology – such as radiofrequency identification (RFID), sensors, or mobile apps – is increasingly used to improve patient safety. This study explored whether the use of “internet of things” (i.e., network of physical objects – “things” – that are embedded with sensors, software or other technology to connect and exchange data with other devices, such as RFID technology) is effective at reducing patient falls and improving hand-hygiene compliance.

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.