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Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.
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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.
    AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report.
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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.
    Patient safety in home care: a multicenter cross-sectional study about medication errors and medication management of nurses.
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    • Strube‐Lahmann S, Müller‐Werdan U, Klingelhöfer‐Noe J, et al. Pharmacol Res Perspect. 2022;10:e00953.
    Patients receiving home care services are vulnerable to medication errors. Based on survey feedback from 485 home care nurses in Germany, this study found that regular medication training and use of quality assurance principles (i.e., double checking) can decrease the incidence of medication errors in home care settings.
    Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.
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    • Savva G, Papastavrou E, Charalambous A, et al. Sr Care Pharm. 2022;37:200-209.
    Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.
    Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study.
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    • Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
    Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
    Survey shows room for improvement with three new best practices for hospitals.
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    • Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5. 

    Practice changes take time to be fully incorporated into daily work. This article shares survey results examining how hospitals implement best practices to enhance the safe use of oxytocin, improve vaccine administration through bar coding, and deploy multifaceted strategies to reduce high-alert medication errors. Gaps in uptake were reviewed and recommendations for improvement shared.
    Management of Cardiac Arrest in Unconventional Locations.
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    • This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms. 

    Fast tracking in cardiac surgery: is it safe?
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    • MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.
    Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.
    Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.
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    • Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;Epub Apri 15.
    People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
    APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.
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    • The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.

    Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.
    Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.
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    • Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.
    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.
    ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.
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    • Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
    This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
    Patient Safety Authority Annual Reports.
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    • 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.
    Intraosseous Line Extravasation in a Pediatric Trauma Patient
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    • 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.

    The effect of clinician feedback interventions on opioid prescribing.
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    • Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
    Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
    Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.
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    • Saleem J, Sarma D, Wright H, et al. J Patient Saf. 2022;18:152-160.
    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.
    Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology.
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    • Nowak B, Schwendimann R, Lyrer P, et al. Int J Environ Res Public Health. 2022;19:2796.
    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.
    Using human factors and ergonomics principles to prevent inpatient falls.
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    • Kwok Y-ting, Lam M-sang. BMJ Open Qual. 2022;11:e001696.
    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.
    ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice.
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    • Am J Health Syst Pharm. 2022;79(7): 564-599.

    Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.
    Diagnostic time-outs to improve diagnosis.
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    • Yale S, Cohen S, Bordini BJ. Crit Care Clin. 2022;38:185-194.
    A broad differential diagnosis can limit missed diagnostic opportunities. This article outlines how diagnostic timeouts, which are intended reduce bias during the identification of differential diagnoses, can improve diagnosis and reduce errors.
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