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Search results for "United States of America"

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Journal Article > Commentary

State sepsis mandates—a new era for regulation of hospital quality.

Hershey TB, Kahn JM. N Engl J Med. 2017;376:2311-2313.

Delays in diagnosis and treatment of sepsis can have serious consequences. This commentary discusses successful programs, built on policy mandates, that aim to ensure effective standardized approaches are in place at health care facilities to prevent harm associated with sepsis.

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

Newspaper/Magazine Article

Medicare failed to investigate suspicious infection cases from 96 hospitals.

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.

Journal Article > Study

Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals.

Pakyz AL, Wang H, Ozcan YA, Edmond MB, Vogus TJ. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Health care–associated infections (HAIs) are a preventable safety problem. This cross-sectional study looked at hospital factors related to HAI incidence. Investigators explored whether the Leapfrog Hospital Safety Score, a composite safety score calculated from publicly reported measures, is associated with HAIs. They also examined the incidence of HAIs in hospitals with Magnet status, conferred by a nurses' trade association in recognition of a positive nursing work environment. Lower Leapfrog safety scores were associated with more Clostridium difficile infections but no differences in other HAIs, and Magnet status was associated with lower rates of methicillin-resistant Staphylococcus aureus infection but worse than expected performance on C. difficile infections. These mixed results do not indicate a strong or consistent relationship between global measures of safety and quality and specific adverse events. A past PSNet interview with Leah Binder, President and CEO of The Leapfrog Group, discussed the development of the Hospital Safety Score.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Audiovisual

The War on Error: Common Diagnostic Errors.

Medscape. 2016–2017.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.

Journal Article > Study

Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.

Mody L, Greene MT, Saint S, et al. Infect Control Hosp Epidemiol. 2017;38:287-293.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.

Journal Article > Study

A hybrid methodology for modeling risk of adverse events in complex health-care settings.

Kazemi R, Mosleh A, Dierks M. Risk Anal. 2017;37:421-440.

This study aimed to use modeling, a strategy to detect safety hazards, to characterize the risk of pressure ulcers and catheter-associated infections. Investigators developed a risk model that combined systems dynamics and Bayesian belief networks to assess organizational and nonorganizational factors that contribute to risks. The model performed well when validated against clinical data, suggesting wider applications of risk modeling may have practical patient safety applications.

Newspaper/Magazine Article

A boy's life is lost to sepsis. Thousands are saved in his wake.

Dwyer J. New York Times. April 13, 2017.

Stories of patient harm due to medical mistakes can serve as catalysts for organizational improvement. This newspaper article reports how an incident involving a pediatric patient who died from sepsis resulted in statewide efforts to improve timely sepsis management.

Journal Article > Study

Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative.

Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Am J Infect Control. 2017;45:13-16.

This retrospective study demonstrated declines in methicillin-resistant Staphylococcus aureus health care–associated infections between 2007–2015. Researchers attribute these results to implementation of the Veterans Affairs MRSA Prevention Initiative. These findings underscore the success of patient safety practices in reducing health care–associated infections.

Journal Article > Study

Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program.

Koenig L, Soltoff SA, Demiralp B, et al. Am J Med Qual. 2016 Dec 19; [Epub ahead of print].

The Centers for Medicare and Medicaid Services (CMS) decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events, including health care–associated infections. Prior research suggests that academic centers and safety-net hospitals may be disproportionately affected by financial penalties imposed by CMS through various pay-for-performance initiatives. In this study, investigators analyzed how hospital size affected performance in the Hospital-Acquired Condition Reduction Program. They concluded that hospital size leads to bias when evaluating hospital performance, disproportionately penalizing larger hospitals when the expected complication rate for a particular event is low. The authors provide numerous suggestions for improving the evaluation of hospital performance within the program.

Journal Article > Review

Impact of Medicare's nonpayment program on hospital-acquired conditions.

  • Classic

Thirukumaran CP, Glance LG, Temkin-Greener H, Rosenthal MB, Li Y. Med Care. 2017;55:447-455.

The Centers for Medicare and Medicaid Services policy on nonpayment for certain hospital-acquired conditions serves as a strong incentive to prevent adverse events during hospitalization. This observational study examined Medicare's nonpayment policy for conditions such as health care–associated infections. As with prior studies, investigators determined that the incidence of hospital-acquired conditions declined following implementation of nonpayment. For certain conditions, such as catheter-associated urinary tract infections, hospitals with a larger proportion of Medicare patients had greater improvements. The authors note the variation in rates of hospital-acquired conditions and differing magnitude of improvement. They recommend further study to understand how to achieve similar successes in reducing hospital-acquired conditions.

Journal Article > Review

Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.

Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

Newspaper/Magazine Article

Zero tolerance for deadly hospital-acquired infections.

Levine H. Consum Rep. 2017 Jan;82:32-40.

Hospital rating systems have yet to receive approval across the health care industry, but they still serve as a way for consumers to select hospitals and providers. This news article reports on publicly available data for central line infections in hospitals across the United States and spotlights checklists as a strategy that contributes to improvement. The article also ranks teaching hospitals based on their performance at preventing central line infections.

Journal Article > Study

Costs and consequences associated with misdiagnosed lower extremity cellulitis.

Weng QY, Raff AB, Cohen JM, et al. JAMA Dermatol. 2016 Nov 2; [Epub ahead of print].

Misdiagnosis is common and can lead to unnecessary care, overuse, and increased costs. According to this study, misdiagnosis of cellulitis may result in anywhere from 50,000 to 130,000 unnecessary hospitalizations annually, leading to hundreds of millions of dollars in needless health care spending.

Newspaper/Magazine Article

Hospitals installed more sinks to stop infections. The sinks can make the problem worse.

Branswell H. STAT. October 25, 2016.

Hospitals have sought to improve hand hygiene with interventions such as room design and sink placement. This news article reports how installation of sinks to enable more frequent handwashing has had unintended consequences and could actually contribute to the spread of bacteria.

Book/Report

Nursing Home Antimicrobial Stewardship Guide.

Rockville, MD: Agency for Healthcare Research and Quality; October 2016.

Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.

Journal Article > Study

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.

Mort E, Bruckel J, Donelan K, et al; Peer-to-Peer Study Team. Am J Med Qual. 2016 Oct 23; [Epub ahead of print].

Patient safety approaches often draw from high reliability industries outside of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear power industry. Two academic medical centers assessed each other's patient safety performance. Each center examined its peer's prevention of central line–associated bloodstream infections (CLABSI), hand hygiene compliance, and overall safety culture as an organization. Peer-to-peer assessments were conducted via site visits, which involved interviews and direct observation. They resulted in rapid practice changes such as dissemination of unit-specific CLABSI rates and central line procedure audits. The process was widely accepted by leaders and frontline staff at both sites. The authors contend that peer-to-peer assessment is feasible and has potential to improve patient safety.

Newspaper/Magazine Article

More than half a million heart surgery patients at risk of a dangerous infection.

Sun LH. The Washington Post. October 13, 2016.

Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.

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