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Search results for ""
Atlanta, GA: Centers for Disease Control and Prevention; 2011.
This report suggests strategies to prevent infections in the outpatient setting and provides links to more detailed infection prevention information.
Journal Article > Commentary
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2013;62:423-425.
This commentary examines unsafe injection practices in the United States and reviews a four-element approach to reduce risks.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Journal Article > Commentary
Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.
Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635.
NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0.
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
This white paper describes recommendations to reduce risks around oral liquid medication administration, including assigning a standard unit of measure (milliliters), using leading zeroes before decimal points (for amounts smaller than one), and ensuring that dosing mechanisms and container labels employ corresponding units of measure.
Journal Article > Commentary
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.
Journal Article > Study
Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.
Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.
This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.
Journal Article > Review
Jackson PD, Biggins MS, Cowan L, French B, Hopkins SL, Uphold CR. Rehabil Nurs. 2016;41:135-148.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surg. 2017;152:784-791.
Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.