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- Education and Training 2
- Error Reporting and Analysis 6
- Legal and Policy Approaches 1
- Quality Improvement Strategies 3
- Research Directions 1
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Identification Errors 1
- Medical Complications 3
- Medication Safety 2
- Surgical Complications
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- North America
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Journal Article > Study
Silber JH, Rosenbaum PR, Trudeau ME, et al. Med Care. 2005;43:122-131.
The authors sought to estimate the severity of first complications after surgery. They found that even seemingly minor complications could have a key effect on the patient's risk of death. The work was primarily funded by AHRQ.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; April 18, 2007.
This announcement alerts health care providers and consumers to potential contamination of medical devices from one manufacturer.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Tools/Toolkit > Government Resource
Agency for Healthcare Research and Quality: Rockville, MD.
Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surg. 2017;152:784-791.
Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.