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Kliff S, Pinkerton B, Weinberger J, Drozdowska A. Vox. October 23, 2017.
This audio segment discusses two incidents involving pediatric patient harm associated with central line use and highlights successful reduction of central line infections after investigation, standardization, and checklist use in many hospitals.
What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019 Apr 23; [Epub ahead of print].
Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.
Thonon H, Espeel F, Frederic F, Thys F. Acta Clin Belg. 2019 Mar 30; [Epub ahead of print].
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Steelman VM, Thenuwara K, Shaw C, Shine L. Jt Comm J Qual Patient Saf. 2019;45:81-90.
ISMP Survey on IV Push Medication Practices.
Institute for Safe Medication Practices.
Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.
Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018;39:897-901.
Latex: a lingering and lurking safety risk.
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database.
Lawal OD, Mohanty M, Elder H, et al. Expert Opin Drug Saf. 2018;17:347-357.
Financial incentives to reduce hospital-acquired infections under alternative payment arrangements.
Cohen CC, Liu J, Cohen B, Larson EL, Glied S. Infect Control Hosp Epidemiol. 2018;39:509-515
Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.
Smith SN, Greene MT, Mody L, Banaszak-Holl J, Petersen LD, Meddings J. BMJ Qual Saf. 2018;27:464-473.
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.
Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Engaging Seriously Ill Older Patients in Advance Care Planning
Daren K. Heyland, MD, MSc
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.
Mody L, Greene MT, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.
A hybrid methodology for modeling risk of adverse events in complex health-care settings.
Kazemi R, Mosleh A, Dierks M. Risk Anal. 2017;37:421-440.
Management of a patient with a latex allergy.
Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.
Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.
Zero tolerance for deadly hospital-acquired infections.
Levine H. Consum Rep. 2017 Jan;82:32-40.
Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.
Mort E, Bruckel J, Donelan K, et al; Peer-to-Peer Study Team. Am J Med Qual. 2017;32:472-479.
Can residents detect errors in technique while observing central line insertions?
Pei K, Merola J, Davis KA, Longo WE. Am J Surg. 2017;213:1166-1170.e1.
Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals.
Hauck KD, Wang S, Vincent C, Smith PC. Med Care. 2017;55:125-130.
Performing the wrong procedure.
Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.
Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize
central line-associated bloodstream infections.
Richter JP, McAlearney AS. Health Care Manage Rev. 2018;43:42-49.
Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review.
Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.
A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.
Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.
Toolkit for Reducing CAUTI in Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.
Gardner AK, Abdelfattah K, Wiersch J, Ahmed RA, Willis RE. J Surg Educ. 2015;72:e158-e162.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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