Narrow Results Clear All
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Indwelling Tubes and Catheters
- Diagnostic Errors 1
- Medical Complications 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 2
Search results for "Indwelling Tubes and Catheters"
Cases & Commentaries
- Spotlight Case
- Web M&M
Vesselin Dimov, MD; April 2009
A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support.
Journal Article > Study
Successful implementation of a unit-based quality nurse to reduce central line–associated bloodstream infections.
Thom KA, Li S, Custer M, et al. Am J Infect Control. 2014;42:139-143.
Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and mortality. Efforts to combat these complications include implementation of checklists and—perhaps more importantly—the enhancement of safety culture. Despite the widespread success of these interventions, some institutions continue to experience CLABSI rates that are above national benchmarks. This study describes the introduction of a unit-based quality nurse dedicated to preventing CLABSIs within a surgical intensive care unit (ICU) at an academic medical center. The quality nurse helped to educate staff about health care–associated infections and prevention strategies. The nurse also provided immediate, direct feedback to staff regarding their compliance with best practices. The average CLABSI rate decreased significantly, even after adjusting for multiple factors including reduction in CLABSI rates in other adult ICUs. A unit-based quality nurse may prove to be a powerful adjunct to the current available tools for reducing these costly infections.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Journal Article > Study
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.