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- Newspaper/Magazine Article 1
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- Clinical Guideline 1
- Grant 1
- Press Release/Announcement 6
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- Medical Complications 13
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United States of America
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Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Audiovisual > Audiovisual Presentation
Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.
This collection of video segments offers information on common types of medical errors, particularly medication errors, based on reports to the Institute for Safe Medication Practices.
10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs.
Rockville, MD: Agency for Healthcare Research and Quality; February 19, 2009.
This announcement highlights a program in 10 states that will test methods of reducing central-line–associated blood stream infections in hospital intensive care units.
Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens.
FDA Alert [US Food and Drug Administration Web site]. March 19, 2009.
This announcement alerts clinicians and patients that insulin pens and insulin cartridges are never to be used on more than one patient.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
This alert notifies health care providers of the potential for patient harm if a particular inhalation powder is reconstituted and incorrectly administered.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.
The near elimination of central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. Although the checklist for CLABSI prevention has been widely publicized, equally important components of the intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety culture in participating ICUs. The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success of the Michigan initiative nationwide, centered around implementation of the CUSP. The initial results, presented in this press release, indicate another remarkable success, with CLABSI rates being reduced by 40% across 1100 participating ICUs. It is notable that these reductions were accomplished even though the baseline rate of CLABSI was already lower than in prior studies. The developer of CUSP, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M in 2010.
Journal Article > Study
The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.
Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S. Soc Sci Med. 2010;71:1692-1701.
This qualitative study examines organizational and contextual factors that influenced the success of an effort to reduce health care–associated infections.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
O'Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2011;52:e162-e193.
This article discusses strategies to prevent catheter-related infections.
Special or Theme Issue
J Am Coll Surg. 2011;212:921-990.
Articles in this special issue explore the effectiveness of AHRQ Patient Safety Indicators in VA hospitals.
Journal Article > Study
CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008.
Scott RD II, Sinkowitz-Cochran R, Wise ME, et al. Health Aff (Millwood). 2014;33:1040-1047.
Multiple national efforts focus on eliminating central line–associated bloodstream infections (CLABSIs), which are a key source of patient harm. Prior investigations have shown that although avoidance of these costly infections results in overall health care savings, hospitals may actually earn more from private payer reimbursements for patients that develop CLABSI. This study adapted a historical economic model to estimate the net benefits of preventing CLABSI in Medicare and Medicaid patients in intensive care units. From 1990 to 2008, approximately 50,000 CLABSIs were avoided in these patients, resulting in net savings ranging from $640 million to $1.8 billion for the federal government. This translates into a per dollar rate of return on Centers for Disease Control and Prevention investments between $3.88 and $23.85. These numbers may all be underestimates since only patients in intensive care units were included, and many patients with CLABSI are in other hospital wards. This study provides support for the business case for patient safety efforts.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
Special or Theme Issue
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.
Legislation/Regulation > Government Resource
Safety considerations to mitigate the risks of misconnections with small-bore connectors intended for enteral applications.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February 11, 2015.
Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015.
Design limitations and production pressure may contribute to insufficient sterilization of complicated medical devices between uses. This announcement raises awareness of risks associated with inadequate cleaning of duodenoscopes that surfaced after a cluster of nosocomial infections at Ronald Reagan UCLA Medical Center.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Journal Article > Study
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.
The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated infections is widely viewed as a catalyst for infection prevention initiatives. This analysis of Medicare fee-for-service claims data shows that following nonpayment policy implementation, there was a substantial increase in claims in which central line–associated bloodstream infections and catheter-associated urinary tract infections were reported to be present on arrival to the hospital. According to this analysis, because CMS continued to reimburse hospitals for conditions present on arrival, the nonpayment policy did not have significant financial impact. The authors conclude that the nonpayment policy for health care–associated infections did not have its intended effect. A past PSNet interview discussed the potential benefits and limitations of insurers not paying for preventable complications.