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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 10
- Legal and Policy Approaches 9
- Quality Improvement Strategies 15
- Specialization of Care 2
- Teamwork 1
- Transparency and Accountability 1
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 3
- Identification Errors 1
- Medical Complications 21
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 4
- Africa 2
- Asia 1
- Australia and New Zealand 1
- Central and South America 1
- Europe 3
- North America 24
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Cases & Commentaries
- Spotlight Case
- Web M&M
James E. Sabin, MD; December 2009
A man with a history of IV drug use is admitted to the hospital and found to have an epidural abscess with surrounding osteomyelitis. Although the treatment plan required weeks of IV antibiotics, the patient (who fought with the nursing staff and threatened to leave against medical advice [AMA]) was discharged after 2 weeks on oral antibiotics. His condition worsened, and he returned 3 weeks later, but he ultimately left AMA and was lost to follow-up.
World Health Organization.
This publication shares news related to the World Health Organization's Global Patient Safety Challenge.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
Legislation/Regulation > Congressional Testimony
Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections.
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office, GAO-09-516T (March 18, 2009) (testimony of Marjorie Kanof, MD).
This Congressional testimony summarizes a 2008 investigation and responds to its findings. It suggests that prioritization of effort, data consistency, and data compatibility are needed to improve health care–associated infection reduction efforts.
Web Resource > Multi-use Website
Geneva, Switzerland: WHO Patient Safety, World Health Organization.
This Web site establishes a forum for hospitals in Europe and Africa to support partnership development and share learnings to drive patient safety improvements.
Journal Article > Study
Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353.
Health care–associated infections are common and the subject of wide-scale prevention programs, despite concerns about their use as a quality metric. This study used a national database to examine the clinical and economic costs attributed to the development of health care–associated sepsis and pneumonia. Analyzing nearly 600,000 cases, investigators found 2.3 million hospitalization days, $8.1 billion in in-hospital costs, and 48,000 preventable deaths attributed to health care–associated sepsis and pneumonia. They also reported at least 40% higher length of stay and costs in patients with these complications who underwent invasive procedures compared to those who did not. Despite limitations in utilizing administrative data to draw clinical details, the findings are notable. A related commentary [see link below] discusses reducing preventable harm in the context of this study's findings, calling for greater investments in the science of health care quality and safety.
Journal Article > Study
Kallen AJ, Mu Y, Bulens S, et al; Active Bacterial Core surveillance (ABCs) MRSA Investigators of the Emerging Infections Program. JAMA. 2010;304:641-648.
Okemos, MI: Michigan Health & Hospital Association; October 2018.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This year's achievements include avoidance of 6392 instances of harm and safety-related savings in the state of nearly $81 million. Areas of focus for improvement work included high reliability, sepsis reduction, and opioid stewardship. The report also summarizes results of the 15-year experience of the collaborative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Allegranzi B, Nejad SB, Castillejos GG, Kilpatrick C, Kelley E, Mathai E; Clean Care is Safer Care Team. Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507.
This report reviewed the literature on health care–associated infections and found it to be the most prevalent adverse event affecting patients worldwide.
Journal Article > Study
Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.
Pakyz AL, Edmond MB. Infect Control Hosp Epidemiol. 2013;34:780-784.
Twenty-seven states mandate reporting of central line–associated bloodstream infections. However, these regulations do not appear to have any effect on infection rates.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Journal Article > Review
Griffith MM, Gross AE, Sutton SH, et al. Clin Infect Dis. 2012;54:684-691.
This review discusses the shortage of anti-infective drugs and argues that the situation should be approached as a public health emergency.
Journal Article > Study
Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.
Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Ann Intern Med. 2012;157:305-312.
The Centers for Medicare and Medicaid Services (CMS) has not reimbursed hospitals for costs associated with certain preventable complications, including catheter–associated urinary tract infections (CAUTI), since 2008. This policy was controversial when implemented, although the actual financial implications to hospitals were unclear. This study from Michigan is one of the first to objectively assess the impact of the CMS policy and found very few cases where payment was denied due to a CAUTI. The incidence of CAUTI was much lower than expected, most likely due to inaccuracies in the billing claims databases used to identify CAUTI. As the accompanying editorial notes, prior research has also cast doubt on the suitability of administrative data for reliably identifying patient safety events.
Journal Article > Study
Ralls MW, Blackwood RA, Arnold MA, Partipilo ML, Dimond J, Teitelbaum DH. Pediatrics. 2012;130:e1369-e1373.
National drug shortages have increased and emerged as a serious patient safety issue in the United States. Recently, a shortage of medicinal-grade ethanol occurred due to a temporary shutdown of the sole supplier. Ethanol lock therapy is used to reduce the incidence of catheter-related blood stream infections (CRBSI) in pediatric patients receiving parenteral nutrition due to intestinal failure. Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest that it was likely due to the risk of an impending Food and Drug Administration inspection. During the shortage, the rate of CRBSI at one hospital rose dramatically, resulting in increased lengths of stay and hospital costs. This evidence illustrates profound financial and patient safety implications related to a national drug shortage.
ISMP Medication Safety Alert! Acute Care Edition. November 28, 2013;18:1-5.
This report analyzes the types of vaccines most commonly associated with errors and identifies concerns related to vaccine prescribing, dispensing, and administration.
Journal Article > Commentary
Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice.
Cortes-Penfield N. Am J Public Health. 2014;104:2060-2065.
This commentary describes the ethical responsibility of frontline practitioners to receive influenza vaccination to prevent hospital-acquired infections. The author reviews evidence supporting vaccination as a preventive strategy, addresses barriers to mandatory vaccination, and recommends that organizations notify patients if they are interacting with a non-vaccinated worker.