Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 3371
Buetti N, Marschall J, Drees M, et al. Infect Control Hosp Epidemiol. 2022;43:553-569.
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.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;Epub Apr 28.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Wright DJ, Gabbay J, Le May A. BMJ Qual Saf. 2022;31:450-461.
Healthcare staff use a variety of skills to implement quality improvement and patient safety initiatives. Using case studies and qualitative interviews, this study outlines six “socio-organisational functional and facilitative tasks” (SOFFTs) necessary to successful implementation of quality improvement initiatives. Findings highlight the importance of technical skills as well as relational skills, training and education, and the ability to consider local context.
Bentley SK, Meshel A, Boehm L, et al. Adv Simul (Lond). 2022;7:15.
In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.
Smith M, Vaughan Sarrazin M, Wang X, et al. J Am Geriatr Soc. 2022;70:1314-1324.
The COVID-19 pandemic disrupted healthcare delivery and contributed to delays in care. Based on a retrospective matched cohort of Medicare patients, this study explored the impact of the COVID-19 pandemic on patients who may be at risk for missed or delayed care. Researchers found that patients with four or more indicators for risk of missed or delayed care (e.g., chronic conditions, frailty, disability affecting use of telehealth) had higher mortality and lower rates of healthcare utilization, including primary care visits.
Hautz WE, Kündig MM, Tschanz R, et al. Diagnosis. 2021;9:241-249.
Diagnostic errors can be identified by measuring concordance of initial and final diagnosis, for instance admission and discharge diagnoses. In this study, researchers developed and tested an automated trigger system to determine concordance between pairs of diagnoses. In comparison to the reference standard (concordance determined by experts) the automated system performance was excellent.

Institute for Healthcare Improvement. Orlando, FL, December 4-7, 2022.

This hybrid conference will offer workshops and interactive sessions exploring strategies from within health care and beyond to improve health care quality. A symposium will be held focusing on improvement science research and application.

ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.
Rockville, MD: Agency for Healthcare Research and Quality; 2019.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey and accompanying toolkit were developed to collect opinions of hospital staff on the safety culture at their organizations. An accompanying database serves as a central repository for hospitals to report their results. Participating hospitals will be able to measure patient safety culture in their institutions and compare results with other sites. Data will be collected for the latest submission period from June 1–July 22, 2022.

National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.

Leadership commitment is crucial to attaining sustainable improvement in patient safety. This “Declaration to Advance Patient Safety” call-to-action shares three steps to motivate work toward implementing change to enhance safe care. First, commit to a national plan for improvement. Second, identify and empower a senior leader and team to assess an organization’s existent safety status. Third, devise plans to measure, design, implement, and support adverse event reduction initiatives.
Johansson H, Lundgren K, Hagiwara MA. BMC Emerg Med. 2022;22:79.
Emergency medical services (EMS) clinicians must decide whether to transport patients to hospitals for emergency care, what level of emergency care they require, or to treat the patient at home and not transport to hospital. This analysis focused on patient safety incidents in Swedish prehospital care that occurred after 2015, following implementation of a protocol allowing EMS clinicians to triage patients to see-and-treat (non-conveyance) or see-and-convey elsewhere. Qualitative analysis of incident reports revealed three themes: assessment of patients, guidelines, and environment and organization. EMS clinicians deviated from the protocol in 34% of cases, putting patients at risk of inappropriate triage to see-and-treat.
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.
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.
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.
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.

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.

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.

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.