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Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
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.
Wisc Med J. 2006:105;1-86.
This special issue includes articles on programs and initiatives to improve the safety of health care. It also includes proceedings from a 2006 Wisconsin conference on patient safety.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
Journal Article > Study
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.
This study is the second phase of the United Kingdom's Safer Patients Initiative (SPI), a large-scale effort to improve patient safety through multifaceted interventions and an independent evaluation. Similar to the first phase study, this one demonstrated little added benefit of SPI on key safety outcomes in 20 hospitals, though overall safety did improve. An accompanying editorial [see link below] discusses the study findings and emphasizes the continued need to run toward science rather than away from it in evaluating quality improvement efforts.
Journal Article > Study
Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.
Armstrong N, Brewster L, Tarrant C, et al. Soc Sci Med. 2018;198:157-164.
Measuring patient safety is critical to improvement. This ethnographic study examined the implementation of a patient safety measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure ulcers, harm from falls, catheter-associated urinary tract infection, and venous thromboembolism, with the goal of informing local improvement efforts. Investigators sought to examine how the measurement program was perceived by frontline staff. Despite the explicit emphasis on using the data for improvement, it was viewed as an external reporting requirement. The program was also viewed as a basis to compare organizations, especially because it included pay-for-performance incentives. The authors suggest that the intention of the program did not match the real-world considerations of participating health care systems and had the unintended consequence of creating potential for blame.
Journal Article > Study
What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.