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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.
Jt Comm J Qual Patient Saf. 2021;47:394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.

Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.

Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations  to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.
Boullata JI, Carrera AL, Harvey L, et al. JPEN J Parenter Enteral Nutr. 2017;41:15-103.
Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.
Heinemann L, Fleming A, Petrie JR, et al. Diabetes Care. 2015;38:716-22.
Insulin is a high-alert medication that can lead to harm if incorrectly administered. Insulin pump problems can be caused by human, mechanical, or drug stability failures. This policy statement describes ways to use adverse event data, manufacturer information, and technical specifications to enhance the safety of insulin therapy.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February 11, 2015.
Mistakes due to small-bore Luer connector similarities can contribute to patient harm. This guidance provides ways for manufacturers, policy makers, and product designers to prevent misconnections, including recommendations regarding improvements for labeling, user testing, and risk assessment.

Sentinel Event Alert. August 20, 2014;(53):1-6.

The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.