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Search results for "Quality Improvement Strategies"
Journal Article > Study
Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.
The remarkable success of the Keystone ICU project was initially publicized as an example of the power of checklists. While checklists are a useful safety tool, this study used an ethnographic approach to better understand the sociological factors that helped the project succeed. The authors highlight the densely networked community, the multimodal interventions, the data-driven processes, and the reframing of catheter-related blood stream infections as a social problem as important contextual factors that must be considered in quality improvement efforts. These lessons are especially important given that subsequent studies have found difficulty in implementing checklists in the absence of a robust safety culture.
Journal Article > Study
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
The term never event was originally coined to describe rare, devastating, and preventable events like wrong-site surgery or fatal medication errors. This definition has expanded over time to include a variety of serious adverse events; for some of them (i.e., certain health care–associated infections), the Centers for Medicare and Medicaid Services denies additional reimbursement. This article sought to determine if eight never events (mostly infectious complications of surgery) are truly preventable, by examining whether baseline patient characteristics could predict which patients would experience a never event. The authors found that incidence of most of these complications could be predicted on the basis of preexisting conditions or the specific surgical procedure performed, calling into question whether these events are truly preventable. This study exemplifies research into the "basic science" of patient safety; a prior commentary called for studies focusing on identifying truly preventable harm and developing accurate, reliable measurement standards.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.