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Search results for ""
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Tools/Toolkit > Government Resource
Atlanta, GA: U.S. Centers for Disease Control and Prevention.
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC) strategy to promote patient safety by reducing infections in health care settings. The site includes fact sheets, a press kit, and other materials to help implement the guidelines.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Journal Article > Study
Fridkin SK, Hageman JC, Morrison M, et al; Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. N Engl J Med. 2005;352:1436-1444.
This surveillance project involving hospital- and populations-level data indicates that acquisition of methicillin-resistant Staphylococcus aureus (MRSA) infection now occurs commonly in community settings.
Legislation/Regulation > Federal Legislation
HR 2234, 109th Cong, 1st Sess (2005).
This bill, which garnered bipartisan support, proposes developing health information technology networks (known as "Regional Health Information Organizations," or RHIOs) with a strong focus on state- and community-based efforts. It is presently under consideration in the United States House of Representatives.
FDA preliminary public health notification: update of information about Ralstonia spp. associated with Vapotherm Respiratory Gas Administration device.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; December 20, 2005.
This safety alert for health care practitioners discusses bacterial contamination of gas devices and recommends alternatives be used until the source of the contamination is identified.
Journal Article > Review
Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.
Johnson JR, Kuskowski MA, Wilt TJ. Ann Intern Med. 2006;144:116-126.
The investigators reviewed the literature on two types of antimicrobial urinary catheters and found that the evidence supports their ability to prevent infection.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Rockville, MD: Agency for Healthcare Research and Quality. June 20, 2007.
This podcast discusses the importance of handwashing to reduce infections in hospitals as well as how consumers can help improve clinician compliance.
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.
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.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
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.
Journal Article > Study
Parente ST, McCullough JS. Health Aff (Millwood). 2009;28:357-360.
Despite widespread interest in the implementation of health information technology (HIT) and a systematic review demonstrating its positive effects on clinical outcomes, use of HIT remains limited. This AHRQ-funded study focused on the relationship between information technology implementation and patient safety by examining the incidence of selected patient safety indicators (PSIs) after implementation of HIT. Modest but significant improvements in some PSIs, including health care–associated infections, were associated with HIT implementation, corroborating the results of a prior study. The study did not assess whether specific elements of HIT, such as computerized provider order entry, were more effective at preventing errors.
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.
Legislation/Regulation > Congressional Testimony
Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections.
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office, GAO-09-516T (March 18, 2009) (testimony of Marjorie Kanof, MD).
This Congressional testimony summarizes a 2008 investigation and responds to its findings. It suggests that prioritization of effort, data consistency, and data compatibility are needed to improve health care–associated infection reduction efforts.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
For health care providers and consumers, this Web site features information, tools, and resources on health care–associated infections (HAIs). AHRQ-funded research and initiatives to reduce HAIs are also highlighted.
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.
Journal Article > Commentary
Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention to new settings.
Kallen AJ, Patel PR, O'Grady NP. Clin Infect Dis. 2010;51:335-341.
This article discusses the epidemiology of catheter-related bloodstream infections and provides recommendations to prevent health care–associated infections outside the intensive care unit.