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Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Journal Article > Study
Successful implementation of a unit-based quality nurse to reduce central line–associated bloodstream infections.
Thom KA, Li S, Custer M, et al. Am J Infect Control. 2014;42:139-143.
Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and mortality. Efforts to combat these complications include implementation of checklists and—perhaps more importantly—the enhancement of safety culture. Despite the widespread success of these interventions, some institutions continue to experience CLABSI rates that are above national benchmarks. This study describes the introduction of a unit-based quality nurse dedicated to preventing CLABSIs within a surgical intensive care unit (ICU) at an academic medical center. The quality nurse helped to educate staff about health care–associated infections and prevention strategies. The nurse also provided immediate, direct feedback to staff regarding their compliance with best practices. The average CLABSI rate decreased significantly, even after adjusting for multiple factors including reduction in CLABSI rates in other adult ICUs. A unit-based quality nurse may prove to be a powerful adjunct to the current available tools for reducing these costly infections.
Journal Article > Commentary
Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.
Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.
The importance of active and engaged hospital leadership in improving safety was highlighted by a Joint Commission Sentinel Event Alert, which challenged hospital executives and boards to establish a culture of safety and systematically analyze and address safety issues. This article details a checklist that hospital leadership can use to organize efforts to eliminate central line–associated bloodstream infections. This AHRQ-funded effort is centered around principles of the comprehensive unit-based safety program and includes specific interventions successfully used in the Keystone ICU project. Prior studies have shown that hospital boards are sometimes surprisingly disengaged from safety efforts, and this article provides a blueprint for executives to direct focused and institution-wide safety projects.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Journal Article > Study
Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-491.
A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.
Journal Article > Study
Saint S, Greene MT, Krein SL, et al. N Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.