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- Culture of Safety 2
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- Error Reporting and Analysis 3
- Human Factors Engineering 3
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- Specialization of Care
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 4
- Medical Complications 8
- Medication Safety 1
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Search results for "Specialized Teams"
- Infectious Diseases
- Specialized Teams
Journal Article > Study
Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-491.
A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.
Journal Article > Study
Saint S, Greene MT, Krein SL, et al. N Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Journal Article > Commentary
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2016;42:122-138.
Early recognition of sepsis is a patient safety issue, due to the time-sensitive nature of delivering evidence-based treatments. This article describes a Centers for Medicare and Medicaid Services–funded initiative to improve sepsis management in 15 facilities in Texas. Components included convening a leadership committee for performance improvement, educating bedside nurses and other staff, developing a screening tool in the electronic health record (EHR), standardizing a second responder protocol (like a rapid response team) for possible sepsis, and conducting audit and feedback for participating institutions. The authors noted challenges given that participating institutions used different EHRs, but they were able to implement EHR-based screening across all systems. Positive screens were evaluated by a second responder, but it is difficult to estimate the amount of second responder time needed for this intervention. Planned outcome measures, which are not yet available, include mortality, length of stay, and costs. A recent WebM&M commentary describes common errors in the early management of sepsis.
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.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Journal Article > Commentary
Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.
Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.
The importance of active and engaged hospital leadership in improving safety was highlighted by a Joint Commission Sentinel Event Alert, which challenged hospital executives and boards to establish a culture of safety and systematically analyze and address safety issues. This article details a checklist that hospital leadership can use to organize efforts to eliminate central line–associated bloodstream infections. This AHRQ-funded effort is centered around principles of the comprehensive unit-based safety program and includes specific interventions successfully used in the Keystone ICU project. Prior studies have shown that hospital boards are sometimes surprisingly disengaged from safety efforts, and this article provides a blueprint for executives to direct focused and institution-wide safety projects.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.