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- Review 1
- Study 3
- Book/Report 3
- Legislation/Regulation 2
- Newspaper/Magazine Article 1
- Special or Theme Issue 1
- Toolkit 1
- Web Resource 2
- Press Release/Announcement 1
Search results for "Device-related Complications"
- Device-related Complications
- Hospital Medicine
- Indwelling Tubes and Catheters
- Quality and Safety Professionals
Journal Article > Review
Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.
Prompt removal of intravenous catheters is critical to preventing health care–associated infections. This systematic review found that persistence of idle, or unused, catheters was associated with adverse outcomes. These findings highlight the need to develop and implement practices to reduce the incidence of idle catheters.
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.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. August 20, 2014;(53):1-6.
The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.
Tallahassee, FL: Florida Hospital Association; August 2013.
Chicago, IL: Health Research & Educational Trust; July 2013.
Journal Article > Study
Dixon-Woods M, Leslie M, Tarrant C, Bion J. Implement Sci. 2013;8:70.
The Matching Michigan program attempted to replicate the success of the Keystone ICU study at preventing central line–associated bloodstream infections in intensive care units (ICUs) in England. However, Matching Michigan was unsuccessful in that infection rates declined at similar rates in both intervention and control units. A counterpart to the landmark study exploring why the Keystone ICU study succeeded, this ethnographic analysis identified external factors (Matching Michigan was perceived as a regulatory, top-down initiative) and internal factors (participating hospitals had widely varying prior experiences with quality improvement projects) that influenced uptake and success of the project at the individual hospital level. Overall, only 1 of the 19 intervention ICUs studied truly transformed their practices and culture toward preventing hospital-acquired infections.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Tools/Toolkit > Measurement Tool/Indicator
Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.
This assessment tool was designed to help hospitals identify and reduce risks of tubing misconnections.
Web Resource > Multi-use Website
Health Research & Educational Trust, MHA Keystone Center.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
This monograph provides guidance, tools, and techniques for hospitals to help decrease central line–associated bloodstream infections.
Journal Article > Commentary
Duval-Arnould J, Mathews SC, Weeks K, et al. Jt Comm J Qual Patient Saf. 2012;38:41-47.
This commentary describes an application used to translate performance-related data into performance estimates to help prevent central line–associated bloodstream infections.
Special or Theme Issue
J Am Coll Surg. 2011;212:921-990.
Articles in this special issue explore the effectiveness of AHRQ Patient Safety Indicators in VA hospitals.
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
This announcement reveals the new National Patient Safety Goal for 2012, which aims to reduce catheter-acquired infections in hospitals.
Journal Article > Study
Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.
Murphy DJ, Needham DM, Goeschel C, Fan E, Cosgrove SE, Pronovost PJ. Am J Med Qual. 2010;25:255-260.
The near-elimination of central line infections in intensive care units in Michigan—powered by a checklist of infection control measures—is one of the leading successes of the patient safety movement. However, this survey finds that few other states have implemented coordinated programs to reduce infections, and most states do not even report infection rates.