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- Epidemiology of Errors and Adverse Events
- Specialized Teams
Journal Article > Commentary
Kronick R, Arnold S, Brady J. JAMA. 2016;316:489-490.
The publication of To Err Is Human in 1999 drew national attention to the issue of patient safety and is often credited with catalyzing widespread efforts to reduce health care–related harm. At the time of the report's publication, central line–associated bloodstream infections (CLABSIs) were considered unpreventable. However, subsequent public reporting programs and the trend toward nonpayment for preventable harm have led not only to a significant reduction in CLABSIs, but a decrease in other types of hospital-acquired conditions as well. This directly translates into improved patient outcomes and reduced health care costs. This commentary highlights progress made in patient safety and suggests that future efforts should focus on improving the measurement of adverse events and mitigating diagnostic error. A past PSNet perspective discussed the evolution of patient safety as it relates to surgery.
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 > Study
Stolldorf DP, Jones CB. Jt Comm J Qual Patient Saf. 2015;41:186-192.
Rapid response teams (RRTs) have been strongly endorsed by organizations including the Institute for Healthcare Improvement, largely based on early results that showed impressive benefits (although later studies were less positive). This study describes RRT programs in hospitals participating in a statewide collaborative that was established to help implement, evaluate, and sustain RRTs at acute care hospitals. Of the 56 hospitals in the collaborative, 31 hospitals responded to the survey, yielding a response rate of 55%. The authors describe the different organizational characteristics and RRT structures at these hospitals. Most of the teams included a critical care nurse and respiratory therapist. About 30% had a hospitalist and 23% reported the presence of a dedicated RRT nurse. Some best practices for safety, process improvement, and oversight were lacking in many of the programs. A prior AHRQ WebM&M perspective explored early lessons from RRTs.
Journal Article > Study
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2015;24:203-211.
Allowing families to activate medical emergency teams (METs) may aid in the early detection of clinical deterioration. However, physicians have expressed concerns that families do not understand when an MET is necessary and that this responsibility could present an undue stress on family members. This study reports on the experience of family-activated MET calls over a 6-year period at an academic children's hospital. There were 83 family-activated MET calls, representing less than 3% of all MET responses at this hospital. Families most frequently requested METs for concerns regarding clinical deterioration, but less than one-quarter of these calls resulted in patients being transferred to an intensive care unit, compared to 60% of clinician-activated METs. Since families called METs only between one to two times per month, the program was not felt to pose a substantial burden. The authors also point out that some family-activated METs identified other clinically relevant information that may not have otherwise been shared with the primary clinical team, as well as important communication issues that could have led to adverse events.