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Journal Article > Study
Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.
Health care–associated infections remain one of the most common preventable adverse events in hospitals, despite some successes at reducing rates of specific infections. Preventing infections caused by methicillin-resistant Staphylococcus aureus (MRSA) remains a difficult problem, as studies of prevention techniques have reached conflicting results. This large-scale study of an MRSA prevention bundle implemented in the Veterans Affairs system found that a multifaceted approach including universal screening, contact isolation precautions, and an emphasis on infection control as part of safety culture resulted in a significant reduction in MRSA infections in both intensive care and ward patients. Although the overall incidence of hospital-acquired MRSA infections has been decreasing nationwide, the effects of these infections can be devastating—as vividly described in this AHRQ WebM&M commentary.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Journal Article > Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.