Skip to main content

All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Additional Filters
1 - 20 of 33
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

Infect Control Hosp Epidemiol. 2022.


Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022 to summarize preemptive actions and implementation strategies for prevention of HAIs.
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.

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.

Sentinel Event Alert. Feb 2, 2021;(62):1-7. 

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic. 

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.
Am Geriatr Soc. 2020;68:908-911.
This policy brief presents the American Geriatric Society’s recommendations for caring for patients with COVID-19 in nursing homes and long-term care facilities. Recommendations focus on the production and distribution of personal protective equipment (PPE), patient transfer between hospitals and nursing homes, public health planning, workforce issues, and payment and tax relief for nursing homes. The brief reflects federal guidance as of April 4, 2020.

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.

SB 3380. 116th Congress (2020).

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.

Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.

Patient safety in the ambulatory environment has received less attention than hospital settings. This guideline provides recommendations to reduce transmission of infectious agents in pediatric ambulatory care, such as policy review and development, education for personnel, and hand hygiene precautions.
D'Alton ME, Friedman AM, Smiley RM, et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.
Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.
Dolan SA, Arias KM, Felizardo G, et al. American journal of infection control. 2016;44:750-7.
Improper injection practices associated with point-of-care testing and treatment can contribute to the spread of health care–associated infections. This position paper outlines how clinicians and infection preventionists can reduce unsafe behaviors with surveillance, oversight, enforcement, individual skills development, and professional accountability.

Sentinel Event Alert. September 28, 2015;(55):1-5.

Falls in the hospital are common, particularly among elderly patients, and falls resulting in serious injury or death are considered never events. This sentinel event alert identified 465 such cases reported to The Joint Commission since 2009 and acknowledges that preventing falls is difficult and complex. The Joint Commission recommends several strategies for preventing falls, including identifying patients at risk for falls, establishing a multidisciplinary fall prevention team, using patient-specific approaches to minimize fall risk, and conducting a post-fall multidisciplinary huddle to detect system flaws. These strategies have been successfully applied and shown to reduce falls in high-quality studies. The role of the physical environment as a risk for falls and the use of post-fall huddles are discussed in a recent AHRQ WebM&M commentary.
Munoz-Price LS, Banach DB, Bearman G, et al. Infect Control Hosp Epidemiol. 2015;36:747-758.
This expert guidance provides recommendations to help hospitals develop policies to reduce the spread of health care–associated infections by individuals visiting patients in isolation. The authors discuss contact precautions and outline specific conditions where these suggestions should be employed.
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections. The guideline is one of the 2014 infection control compendium updates published in the journal.
Sentinel Event Alert. 2014;June 16:1-6.
The Joint Commission has issued a sentinel event alert regarding infections caused by the misuse of vials, prompted by at least 49 outbreaks related to this problem since 2001. The reuse of single-dose vials has resulted in documented transmission of bacteria and hepatitis B and C viruses. Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management and cancer clinics. More than 150,000 patients required notification and further testing due to concern of potential exposure to unsafe injections. This alert outlines recommendations and potential strategies for improvement, including resources related to the Centers for Disease Control and Prevention's (CDC) One & Only Campaign, which promotes using "one needle, one syringe, only one time." The report also emphasizes teaching safe practices and establishing safety culture. CDC has previously issued guidelines on appropriate use of single-dose vials.
Talbot TR, Bratzler DW, Carrico RM, et al. Ann Intern Med. 2013;159:631-635.
Public reporting of health care–associated infection rates serves as a key measure for quality in hospitals. This commentary reveals limitations to using these metrics, such as variation in definitions, and outlines standards to guide the collection and utilization of surveillance data.