The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.

Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification.  In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.

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.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.  

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Emergency and internal medicine residents attended a course on central venous access that included lectures, videos, and simulation using a task trainer. Comparison of pre- and post-training evaluation demonstrated significant improvement in knowledge, confidence, and procedural skills.