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- Review 2
- Study 13
- Audiovisual 6
- Book/Report 15
- Legislation/Regulation 2
- Newspaper/Magazine Article 4
- Special or Theme Issue 2
- Toolkit 7
- Web Resource 43
- Clinical Guideline 1
- Grant 2
- Press Release/Announcement 7
- Communication Improvement 4
- Culture of Safety 5
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Error Reporting and Analysis
- Error Reporting 12
- Human Factors Engineering 5
- Legal and Policy Approaches 9
- Logistical Approaches 2
- Quality Improvement Strategies 28
- Research Directions 1
- Specialization of Care 2
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- Device-related Complications 11
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Nosocomial Infections
- Medication Safety 9
- Surgical Complications 4
- Family Members and Caregivers 1
- Health Care Executives and Administrators 50
- Health Care Providers 46
Non-Health Care Professionals
- Media 1
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United States of America
- United States Federal Government
- United States of America
Search results for "Nosocomial Infections"
- Department of Health and Human Services (HHS)
- Nosocomial Infections
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Tools/Toolkit > Fact Sheet/FAQs
Gray D, Azam I. Rockville, MD: Agency for Healthcare Research and Quality; October 2018. AHRQ Publication No. 18(19)-0033-4-EF.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements in areas of focus such as hospital-acquired infections. The most recent update documented more than two-thirds improvement in patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Web Resource > Government Resource
QualityNet. Centers for Medicare and Medicaid Services.
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.
Journal Article > Study
Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.
Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018;39:897-901.
The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated infections is widely viewed as a catalyst for infection prevention initiatives. This analysis of Medicare fee-for-service claims data shows that following nonpayment policy implementation, there was a substantial increase in claims in which central line–associated bloodstream infections and catheter-associated urinary tract infections were reported to be present on arrival to the hospital. According to this analysis, because CMS continued to reimburse hospitals for conditions present on arrival, the nonpayment policy did not have significant financial impact. The authors conclude that the nonpayment policy for health care–associated infections did not have its intended effect. A past PSNet interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Journal Article > Study
One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
Kossover-Smith RA, Coutts K, Hatfield KM, et al. Am J Infect Control. 2017;45:1018-1023.
Unsafe injection practices in health care settings have led to more than 50 disease outbreaks in the past 20 years. In this cross-sectional, voluntary survey across 8 states, 12% of responding physicians stated that needles were reused between patients in their workplace. Nearly 8% of physicians thought this was an acceptable practice. The authors discuss implications for the Center for Disease Control and Prevention's One & Only safe injection campaign.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Jewett C. Kaiser Health News. May 9, 2017.
The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; October 13, 2016. PA-17-007 and PA-17-008.
Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through January 26, 2021 for the R18 funding and March 6, 2021 for the R01 funding.
Journal Article > Government Resource
Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.
Novosad SA, Sapiano MR, Grigg C, et al. MMWR Morb Mortal Wkly Rep. 2016;65:864-869.
Sepsis has been a significant focus of quality improvement initiatives. In this retrospective review, researchers sought to identify patient characteristics, risk factors, and infections that might inform sepsis diagnosis, treatment, and prevention efforts. The medical records of a random sample of 246 adult and 79 pediatric patients with codes for severe sepsis or septic shock across 4 New York hospitals were reviewed. Investigators found that 72% of patients had exposure to at least one health care factor during the 30 days prior to being admitted for sepsis or a medical condition requiring frequent health care contact. Pneumonia was the most frequently documented infection causing sepsis. They concluded that reducing sepsis will require an ongoing focus on infection prevention.
CDC Vital Signs. August 23, 2016.
CDC Vital Signs. March 3, 2016.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
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.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.
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.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
Use of incompletely cleaned medical devices has been linked to health care–associated infections. Drawing from reports submitted to the FDA regarding infections related to reprocessed flexible bronchoscopes, this announcement offers recommendations to enhance the reliability of scope sterilization methods.
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.
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.