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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Audiovisual

Making health care safer. Think sepsis. Time matters.

CDC Vital Signs. August 23, 2016.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Journal Article > Commentary

Incorporating quality and safety values into a CLABSI simulation experience.

Liebrecht CM, Lieb MC. Nurs Forum. 2017;52:118-123.

Simulation has been promoted as a way to teach nurses about potential errors in their practice. This commentary describes the development of a program to help nurses recognize and correct weaknesses in their care processes that increase risk of central line–associated bloodstream infection.

Book/Report

Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.

Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.

Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.

Book/Report

Antibiotic Stewardship in Acute Care: A Practical Playbook.

National Quality Partners. Washington, DC: National Quality Forum; 2016.

Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.

Journal Article > Study

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.

  • Classic

Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.

Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.

Newspaper/Magazine Article

Living with cancer: not talking about medical mistakes.

Gubar S. New York Times. October 30, 2014.

This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.

Journal Article > Study

Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.

Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.

Catheter-associated infections are common, and largely preventable, adverse events. Though incidence of these events has declined due to intensive safety efforts, one factor contributing to intravenous catheter infections is the failure to remove unnecessary central venous catheters (CVCs). This study sought to determine whether inpatient physicians know which of their patients have CVCs in place by comparing physician response to direct observation of each patient. Physicians were unaware of CVCs in about 20% of the cases examined. Trainee physicians were more likely to be aware of a CVC than teaching attending physicians or hospitalists, and critical care physicians were more likely to know about a CVC than general medicine physicians. These findings suggest that interventions to reduce CVC-associated infections should address clinician awareness of CVCs. An AHRQ WebM&M commentary discusses best practices for removing CVCs.

Special or Theme Issue

From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.

This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.

Journal Article > Study

On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile.

Weaver SJ, Weeks K, Pham JC, Pronovost PJ. Am J Infect Control. 2014;42(suppl 10):S203-S208.

This study determined that results from the AHRQ Hospital Survey on Patient Safety were associated with differences in central line–associated bloodstream infection rates. The authors found five different overall patterns of responses which they propose as distinct safety climates. These results argue for integrating survey results rather than testing whether each separate aspect of safety climate is linked to a particular safety problem.

Journal Article > Commentary

Hand hygiene compliance for patient safety.

Aziz A. Brit J Healthc Manag. 2014;20:428-434.

Health care–associated infections (HAIs) remain a major contributor to preventable morbidity and mortality in hospitalized patients, despite some progress in combating certain infections. This commentary relates how hand hygiene compliance contributes to infection prevention and safe care.

Audiovisual > Audiovisual Presentation

Applying High Reliability Principles to Infection Prevention and Control in Long Term Care.

Oakbrook Terrace, IL: Joint Commission; 2014.

Safety problems, particularly medication errors and poor hand hygiene compliance, are common in nursing homes. This Web site offers an online learning module and related information about how to apply high reliability concepts to reduce health care–associated infections in long-term care settings.

Journal Article > Commentary

Strategies to prevent healthcare-associated infections through hand hygiene.

Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.

Hand hygiene adherence is a key target for improving patient safety. This guideline offers an overview of evidence-based strategies to monitor and promote hand hygiene, including resources developed by the Centers for Disease Control and Prevention and the World Health Organization's "5 moments" program. The authors provide detailed practice recommendations to increase hand hygiene compliance as a way to reduce health care–associated infections.

Journal Article > Review

Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review.

Goutier JM, Holzmueller CG, Edwards KC, Klompas M, Speck K, Berenholtz SM. Infect Control Hosp Epidemiol. 2014;35:998-1005.

Ventilator-associated pneumonia is one of the most common health care–associated infections in intensive care unit patients. This systematic review identifies several strategies, including standardization of care processes, performing regular data audits, and providing feedback, that can enhance adoption of evidence-based preventive strategies.

Legislation/Regulation > Sentinel Event Alerts

Preventing infection from the misuse of vials.

Sentinel Event Alert. June 16, 2014;(52):1-6.

The Joint Commission has issued a sentinel event alert regarding infections caused by the misuse of vials, prompted by at least 49 outbreaks related to this problem since 2001. The reuse of single-dose vials has resulted in documented transmission of bacteria and hepatitis B and C viruses. Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management and cancer clinics. More than 150,000 patients required notification and further testing due to concern of potential exposure to unsafe injections. This alert outlines recommendations and potential strategies for improvement, including resources related to the Centers for Disease Control and Prevention's (CDC) One & Only Campaign, which promotes using "one needle, one syringe, only one time." The report also emphasizes teaching safe practices and establishing safety culture. CDC has previously issued guidelines on appropriate use of single-dose vials.

Book/Report

Advances in the Prevention and Control of HAIs.

  • Classic

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.

Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.

Journal Article > Study

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008.

Scott RD II, Sinkowitz-Cochran R, Wise ME, et al. Health Aff (Millwood). 2014;33:1040-1047.

Multiple national efforts focus on eliminating central line–associated bloodstream infections (CLABSIs), which are a key source of patient harm. Prior investigations have shown that although avoidance of these costly infections results in overall health care savings, hospitals may actually earn more from private payer reimbursements for patients that develop CLABSI. This study adapted a historical economic model to estimate the net benefits of preventing CLABSI in Medicare and Medicaid patients in intensive care units. From 1990 to 2008, approximately 50,000 CLABSIs were avoided in these patients, resulting in net savings ranging from $640 million to $1.8 billion for the federal government. This translates into a per dollar rate of return on Centers for Disease Control and Prevention investments between $3.88 and $23.85. These numbers may all be underestimates since only patients in intensive care units were included, and many patients with CLABSI are in other hospital wards. This study provides support for the business case for patient safety efforts.

Journal Article > Review

Automated and electronically assisted hand hygiene monitoring systems: a systematic review.

Ward MA, Schweizer ML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. Am J Infect Control. 2014;42:472-478.

This systematic review evaluated new technologies for assisting hand hygiene monitoring, including automated counting systems, video monitoring, and fully automated monitoring systems. Currently, there is very limited data about how accurate, effective, and valuable these strategies are in enhancing hand hygiene compliance.

Journal Article > Study

Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.

Munoz-Price LS, Patel Z, Banks S, et al. Infect Control Hosp Epidemiol. 2014;35:717-720.

Hand hygiene rates remain disappointingly low among physicians and nurses, despite appropriate handwashing being an essential factor in preventing health care–associated infections. In this study, installing a hand sanitizer dispenser on the anesthesia machine resulted in only a limited increase in the frequency of hand sanitization by anesthesiologists.

Newspaper/Magazine Article

Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

Catalanello R. The Times-Picayune. April 15, 2014.

Reporting on the investigation into an incident where five pediatric patients died after acquiring a health care–associated infection, this newspaper article describes how delays in diagnosis and treatment along with inadequate communication contributed to patient harm.

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