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Hildy Schell-Chaple, RN, PhD; September 2019
After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later, the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later.
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.
Journal Article > Review
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.
Journal Article > Study
Pei K, Merola J, Davis KA, Longo WE. Am J Surg. 2017;213:1166-1170.e1.
The use of video technology has been shown to facilitate error analysis. In this randomized study, general surgery residents who viewed an instructional video on proper central line insertion technique were better able to identify errors associated with improper technique compared to those who did not watch the instructional video.
Journal Article > Study
Chang BH, Hsu YJ, Rosen MA, et al. Am J Med Qual. 2019 May 3; [Epub ahead of print].
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.