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- WebM&M Cases 1
- Perspectives on Safety 1
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- Book/Report 1
- Legislation/Regulation 3
- Newspaper/Magazine Article 1
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- Press Release/Announcement 1
- Communication Improvement 1
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- Error Reporting and Analysis 7
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Search results for "Medicine"
Journal Article > Commentary
Hershey TB, Kahn JM. N Engl J Med. 2017;376:2311-2313.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Journal Article > Review
U.S. compounding pharmacy-related outbreaks, 2001–2013: public health and patient safety lessons learned.
Shehab N, Brown MN, Kallen AJ, Perz JF. J Patient Saf. 2018;14:164-173.
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.
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.
Cases & Commentaries
- Web M&M
Richard Rothman, MD, PhD; Sahael Stapleton, MD; May 2011
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Journal Article > Study
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors, including selected never events and hospital-acquired infections. The impact of the policy was debated, including the ability of providers and systems to accurately identify conditions present on admission. This study involved an educational intervention to assess the policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the intervention group, who received education about the new policy as part of the study, were less likely than participants who received no such education to select the most clinically appropriate response. While all the trainees acknowledged responsibility to understand CMS documentation rules and felt poorly trained to do so, their responses to the vignettes raised concern about the potential harm and unintended consequences caused by unnecessary testing and procedures that may result from the policy. The implications of the CMS policy are further discussed in an AHRQ WebM&M perspective.
Journal Article > Commentary
Stone PW, Glied SA, McNair PD, et al. Med Care. 2010;48:433-439.
Reporting on a consensus conference, this article outlines a research agenda to determine the influence of financial incentives on patient safety improvement efforts.
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.
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.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.