Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "United States of America"

1 - 20 of 321 results
Download Selected Citations

Show: 20 | 50 | 100

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.

Journal Article > Study

Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events.

Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.

Patients requiring intensive care are particularly vulnerable to preventable adverse events, including health care–associated infections. This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients requiring mechanical ventilation in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the Comprehensive Unit-based Safety Program, focusing on implementing evidence-based safety processes by explicitly addressing barriers to improvement and engaging in regular data audit and feedback. Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including ventilator-associated pneumonia) over the study period. Although the study is limited by lack of a concurrent control group, the results indicate the power of collaborative efforts to drive large-scale improvement.

Journal Article > Commentary

Improving infusion pump safety through usability testing.

Miller KE, Arnold R, Capan M, et al. J Nurs Care Qual. 2017;32:141-149.

Usability testing is an important step toward safely integrating new technologies into medical practice. This commentary describes the testing processes used for an infusion pump integration initiative. The authors highlight the importance of proactively identifying and addressing potential failures when introducing new equipment.

Journal Article > Commentary

Retained lumbar catheter tip.

DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.

Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.

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.

Journal Article > Commentary

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

Newspaper/Magazine Article

Accidental IV infusion of heparinized irrigation in the OR.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.

Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.

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.

Journal Article > Commentary

Infusion medication error reduction by two-person verification: a quality improvement initiative.

Subramanyam R, Mahmoud M, Buck D, Varughese A. Pediatrics. 2016;138:e20154413.

Infusion pump programming is vulnerable to human error. This commentary describes how an improvement initiative tested a two-person verification strategy. Project leaders employed educational and feedback strategies along with plan-do-study-act cycles. The initiative resulted in reduced errors in pump programming and improvements in safety culture.

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.

Newspaper/Magazine Article

ECRI out with 10 deadly healthcare technology hazards for 2017.

Monegain B. Healthcare IT News. November 7, 2016.

This news article discusses findings of an annual consensus report identifying health care technology hazards likely to be associated with accidental patient harm. Key concerns highlighted include inadequate sterilization of reusable instruments and smart pump programming errors.

Journal Article > Commentary

ASPEN Safe Practices for Enteral Nutrition Therapy.

Boullata JI, Carrera AL, Harvey L, et al; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2017;41:15-103.

Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.

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.

Journal Article > Commentary

Changing smart pump vendors: lessons learned.

Arthur KJ, Catlin AC, Quebe A, Washington A. Hosp Pharm. 2016;51:782-789.

Changes in processes, devices, and technologies can increase risk of human error. This commentary discusses how switching from one smart pump system to another can have unintended consequences and recommends tactics to prevent the problems associated with implementing new technology from reaching patients.

Journal Article > Commentary

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.

Journal Article > Study

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.

Richter JP, McAlearney AS. Health Care Manage Rev. 2016 Aug 15; [Epub ahead of print].

The Comprehensive Unit-based Safety Program (CUSP) reduced central line–associated bloodstream infections (CLABSI) in intensive care units nationwide, but its effectiveness varies among settings. This analysis found that units with a strong safety culture had greater success in lowering CLABSI with CUSP implementation than units with a worse safety culture. The authors suggest addressing a unit's safety culture prior to implementing CUSP to augment its impact.

Journal Article > Review

Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review.

Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.

Prompt removal of intravenous catheters is critical to preventing health care–associated infections. This systematic review found that persistence of idle, or unused, catheters was associated with adverse outcomes. These findings highlight the need to develop and implement practices to reduce the incidence of idle catheters.

Journal Article > Commentary

Capturing essential information to achieve safe interoperability.

Weininger S, Jaffe MB, Rausch T, Goldman JM. Anesth Analg. 2017;124:83-94.

This commentary discusses how clinical scenarios can reveal potential barriers to interoperability between health information systems and medical devices to ensure they are effectively integrated to support safe clinical workflow, process documentation, and data sharing. The authors describe a patient-controlled analgesia failure to illustrate the scenario method. A previous WebM&M commentary discussed risks inherent in lack of system interoperability.

Back to Top