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Search results for "Hospitals"

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Journal Article > Review

A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.

Leis JA, Shojania KG. BMJ Qual Saf. 2017;26:572-577.

Although plan–do–study–act (PDSA) cycles were promoted as an in-depth rapid-cycle improvement mechanism, this process can fall short of advancing an organization's improvement work. Exploring shortcomings as reflected in the literature, this article relates insights drawn from a project review to discuss how to effectively use PDSA cycles in patient safety work.

Journal Article > Organizational Policy/Guidelines

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

Ban KA, Minei JP, Laronga C, et al. J Am Coll Surg. 2017;224:59-74.

Surgical site infections are a persistent and costly challenge to patient safety. These guidelines provide recommendations to reduce this common hospital-acquired condition, including policies for surgeon attire, hand hygiene, and equipment sterilization.

Journal Article > Commentary

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

D'Alton ME, Friedman AM, Smiley RM et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.

Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.

Journal Article > Commentary

Improving the communication between teams managing boarded patients on a surgical specialty ward.

Puvaneswaralingam S, Ross D. BMJ Qual Improv Rep. 2016;5.

Boarding patients as they transfer between wards can compromise patient safety. This commentary reviews how an otolaryngology ward implemented a simple cognitive aid to improve patient record review, information sharing, and team communication. The authors report the results of the project and how they intend to use plan-do-study-act cycles to refine the process.

Journal Article > Study

Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?

Sarrechia M, Van Gerven E, Hermans L, et al. J Adv Nurs. 2013;69:278-285.

A considerable body of literature documents widespread variations in outcomes for patients hospitalized at different hospitals for similar conditions. Care pathways are intended to improve outcomes by standardizing use of evidence-based practices, and a surgical pathway was recently shown to markedly reduce both complications and postoperative mortality. However, this survey of obstetric care pathways for normal deliveries at Belgian hospitals found that the 17 pathways analyzed varied widely and did not consistently apply evidence-based practices to prevent postpartum complications. A devastating series of preventable complications during delivery, which led to the death of an infant, is discussed in this classic commentary, and lessons learned from the case have been incorporated into a video widely used for teaching purposes.

Journal Article > Study

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

White CM, Statile AM, Conway PH, et al. Pediatrics. 2012;129:e1042-e1050.

This study highlights the importance of instituting a project champion to drive improvements in physician hand-hygiene compliance rates.

Journal Article > Commentary

Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives.

Styer KA, Ashley SW, Schmidt S, Zive EM, Eappen S. AORN J. 2011;94:590-598.

This commentary describes how one hospital implemented the WHO surgical safety checklist in a 2-week plan-do-study-act trial and identified areas for improvement.

Journal Article > Review

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.

Checklists have resulted in some of the most prominent successes of the patient safety movement, and the resulting publicity has led to wider implementation of checklists in a variety of care settings. This rapid dissemination of checklists has been accompanied by cautionary notes from those who have examined successful checklist-based interventions, who stress the importance of safety culture and other factors in ensuring intervention success. This systematic review of nine published studies of checklists also strikes a cautionary note, finding only moderate evidence that checklists are associated with safety improvements and noting significant methodological weaknesses in the existing literature base. Checklists are a powerful improvement tool, but as this study highlights, their success is often dependent on other interventions.

Book/Report

Eliminating CLABSI: A National Patient Safety Imperative.

Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.

This publication reports the impact hospital participation in CUSP had on patients. This AHRQ-funded program was designed to reduce central line infections using concepts tested in the successful Keystone program.

Journal Article > Commentary

Perfusion safety: new initiatives and enduring principles.

Kurusz M. Perfusion. 2011;26(suppl 1):6-14.

This commentary discusses efforts to improve perfusion safety.

Journal Article > Study

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.

Journal Article > Commentary

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

This commentary discusses the development and implementation of a count procedure that successfully reduced incidence of retained sponges following labor and delivery.

Journal Article > Study

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

This follow-up from the Keystone ICU study found that the majority of participating hospitals were able to eliminate central line–associated bloodstream infections for more than 1 year, with one-quarter having no infections for more than 2 years.

Journal Article > Study

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

Chan J, Shojania KG, Easty AC, Etchells EE. J Am Med Inform Assoc. 2011;18:276-281.

A user-centered design format for computerized provider order entry order sets proved to be more efficient and usable than standard formats, with no difference in prescribing error rates.

Newspaper/Magazine Article

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.

Journal Article > Study

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

  • Classic

Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.

Health care–associated infections remain one of the most common preventable adverse events in hospitals, despite some successes at reducing rates of specific infections. Preventing infections caused by methicillin-resistant Staphylococcus aureus (MRSA) remains a difficult problem, as studies of prevention techniques have reached conflicting results. This large-scale study of an MRSA prevention bundle implemented in the Veterans Affairs system found that a multifaceted approach including universal screening, contact isolation precautions, and an emphasis on infection control as part of safety culture resulted in a significant reduction in MRSA infections in both intensive care and ward patients. Although the overall incidence of hospital-acquired MRSA infections has been decreasing nationwide, the effects of these infections can be devastating—as vividly described in this AHRQ WebM&M commentary.

Newspaper/Magazine Article

Delivering results.

Landro L. Wall Street Journal. March 28, 2011.

This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Newspaper/Magazine Article

MGH faces suit over drug error that killed woman.

Valencia MJ. Boston Globe. March 10, 2011.

This newspaper article reports on a fatal medication error involving an anticoagulant overdose.

Journal Article > Study

A comprehensive obstetrics patient safety program improves safety climate and culture.

Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-e6.

A multifaceted patient safety program resulted in a sustained improvement in safety culture in an academic obstetrics unit. The program had previously been shown to reduce the incidence of preventable adverse events.

Journal Article > Study

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

The near-elimination of catheter-related bloodstream infections (CRBSI) in adult intensive care units in Michigan propelled checklists into popular discourse, and stands as one of the landmark achievements of the patient safety field. In this study conducted at all 18 neonatal intensive care units (NICUs) in New York State, use of checklists for central line insertion and maintenance was associated with a marked overall reduction in CRBSI. However, wide variation in infection rates remained between individual NICUs, and hospitals with higher CRBSI rates used the checklists inconsistently. This study demonstrates that effective use of checklists also depends on many local factors, principally the institutional safety culture.

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