Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 5
- Education and Training 6
Error Reporting and Analysis
- Error Reporting 12
- Human Factors Engineering 11
- Legal and Policy Approaches 7
- Logistical Approaches 2
- Quality Improvement Strategies 25
- Specialization of Care 5
- Teamwork 2
- Technologic Approaches 3
- Device-related Complications 7
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 4
- Interruptions and distractions 1
- Nosocomial Infections
- Medication Safety 10
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 12
- Transfusion Complications 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators 43
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 3
- Patients 8
- Australia and New Zealand 1
- Europe 2
- Canada 2
Search results for "Nosocomial Infections"
- Nosocomial Infections
Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.
The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.
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.
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.
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
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.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
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.
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.
Atlanta, GA: Centers for Disease Control and Prevention; 2011.
This report suggests strategies to prevent infections in the outpatient setting and provides links to more detailed infection prevention information.
Edmonton, AB, Canada: Canadian Patient Safety Institute; March 2011.
Explaining the importance of hand hygiene in the health care setting, this publication provides strategies for patients and families to prevent spreading health care–associated infections.
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
This report describes how teams participating in The Joint Commission's Center for Transforming Healthcare hand hygiene initiative utilized techniques to examine hand hygiene processes and identified the most common reasons why clinicians don't wash their hands.
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.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.