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Perspectives on Safety > Interview
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
Journal Article > Study
An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program.
Hicks RW, Becker SC. J Infus Nurs. 2006;29:20-27.
The authors analyzed 5 years' worth of Medmarx data and found three trends in intravenous drug administration that predisposed patients to harm: product shortages, calculation errors, and tubing interconnectivity.
Journal Article > Study
Risk management, or just a different risk: a national survey of newborn units following a patient safety alert.
Freer Y, Lyon A. Arch Dis Child Fetal Neonatal Ed. 2006;91:F327-F329.
The investigators conducted a survey of neonatal units in the United Kingdom to determine whether practices were changed following clinical alerts. They conclude that recommendations for changes need to be supported by clinical evidence.
Journal Article > Commentary
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
High-reliability organizations (eg, the aviation industry) have developed methods for achieving safety despite hazardous conditions. This study describes the development of a framework to achieve high reliability in the intensive care unit (ICU) context and discusses its application to the problem of preventing catheter-related bloodstream infections. The framework is based on a previously published method for evaluating safety interventions; the key elements include selecting measurable outcomes, applying evidence-based interventions, ensuring the intervention reaches all patients, and improving the overall culture of safety. The investigators applied this approach in ICUs in Michigan and achieved significant reductions in the incidence of catheter-related bloodstream infections.
Web Resource > Multi-use Website
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
Institute for Safe Medication Practices.