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Cases & Commentaries
- Web M&M
Marta L. Render, MD; May 2012
After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.
Journal Article > Study
Cumbler E, Castillo L, Satorie L, et al. J Nurs Care Qual. 2013;28:304-311.
The seemingly simple act of hand hygiene has proved to be a formidable obstacle in patient safety, as hand hygiene rates remain unacceptably low at many hospitals. This study describes how one hospital reframed hand washing as a social issue at the unit level and used a combination of active leadership and psychological approaches (including immediate feedback) to encourage hand hygiene. The program resulted in a sustained improvement in hand hygiene rates, an accomplishment that has led to a drop in health care–associated infection rates in other studies. The seminal Keystone ICU study used a similar approach—framing infection control as a social issue rather than a disease problem—to successfully reduce catheter-associated bloodstream infections.