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Journal Article > Study
Wanta BT, Glasgow AE, Habermann EB, et al. Surg Infect (Larchmt). 2016;17:755-760.
Surgical site infections are an important type of health care–associated infection that safety efforts aim to prevent. This case-control study compared patients matched on age, gender, and elective procedure who developed surgical site infections with those who did not. Although investigators hypothesized that having additional personnel in the operating room would lead to higher likelihood of infection, after adjusting for patient- and procedure-related factors, they found this was not the case.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Journal Article > Commentary
Anderson KT, Appelbaum R, Bartz-Kurycki MA, Tsao K, Browne M. Semin Pediatr Surg. 2018;27:92-101.
Clinical skill development in surgery is evolving beyond technical expertise as focus has shifted to how teamwork and human factors affect safety. This commentary describes three key activities associated with surgical safety efforts, including monitoring surgical quality through national data analysis, bundling field-tested processes to prevent surgical site infections, and utilizing surgical checklists.
Journal Article > Study
Al Mohajer M, Joiner KA, Nix DE. Acad Med. 2018;93:1827-1832.
The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Centers for Medicare and Medicaid Services (CMS) and withholds payment to hospitals for several hospital-acquired conditions deemed to be preventable sources of patient harm. Prior research has shown that teaching hospitals, hospitals caring for more complicated and high-risk patients, and safety-net hospitals may be more likely to experience financial penalties under HACRP compared to nonteaching hospitals caring for less sick patients. These findings raised concerns regarding the possible unintended consequences related to pay-for-performance. Researchers sought to identify factors associated with HACRP performance and penalties. They found that teaching institutions and hospitals with higher case-mix index, length of stay, and those located in the Northeast or Western United States were more likely to receive penalties under the CMS program. A previous WebM&M commentary discussed the unintended consequences associated with publicly reported health care quality measures.
Journal Article > Review
The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis.
Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP; Swissnoso. Infect Control Hosp Epidemiol. 2018;39:1277-1295.
Health care–associated infections (HAIs) represent a significant source of preventable harm to patients. Targeted interventions have been shown to be effective in decreasing HAIs and events once deemed unavoidable, such as central line–associated bloodstream infections, are now considered preventable. In this systematic review and meta-analysis, investigators sought to determine the proportion of HAIs prevented by infection control efforts across countries of different income levels. From the 144 studies ultimately included in the analysis, they found that implementation of evidence-based interventions was associated with an overall reduction in HAIs and that there was no relationship to the financial status of the country in which the study was conducted. A past PSNet perspective discussed infection prevention and patient safety.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.