Narrow Results Clear All
- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 3
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Technologic Approaches 1
Search results for ""
Cases & Commentaries
- Web M&M
Hilary M. Babcock, MD; Victoria J. Fraser, MD; June 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
Journal Article > Study
Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
Catheter-associated infections are common, and largely preventable, adverse events. Though incidence of these events has declined due to intensive safety efforts, one factor contributing to intravenous catheter infections is the failure to remove unnecessary central venous catheters (CVCs). This study sought to determine whether inpatient physicians know which of their patients have CVCs in place by comparing physician response to direct observation of each patient. Physicians were unaware of CVCs in about 20% of the cases examined. Trainee physicians were more likely to be aware of a CVC than teaching attending physicians or hospitalists, and critical care physicians were more likely to know about a CVC than general medicine physicians. These findings suggest that interventions to reduce CVC-associated infections should address clinician awareness of CVCs. An AHRQ WebM&M commentary discusses best practices for removing CVCs.
National Quality Partners. Washington, DC: National Quality Forum; 2016.
Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.
Journal Article > Study
One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
Kossover-Smith RA, Coutts K, Hatfield KM, et al. Am J Infect Control. 2017;45:1018-1023.
Unsafe injection practices in health care settings have led to more than 50 disease outbreaks in the past 20 years. In this cross-sectional, voluntary survey across 8 states, 12% of responding physicians stated that needles were reused between patients in their workplace. Nearly 8% of physicians thought this was an acceptable practice. The authors discuss implications for the Center for Disease Control and Prevention's One & Only safe injection campaign.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.