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Search results for "United States of America"

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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 > 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.

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.

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 > 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

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 > Study

A program to prevent catheter-associated urinary tract infection in acute care.

  • Classic

Saint S, Greene MT, Krein SL, et al. N Engl J Med. 2016;374:2111-2119.

The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.

Journal Article > Review

A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.

Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.

Interventions intended to enhance patient safety may have unanticipated consequences. This systematic review found that unintended consequences of patient safety interventions, positive and negative, are common. Researchers recommend that all patient safety interventions should be monitored for these unexpected outcomes.

Tools/Toolkit > Government Resource

Toolkit for Reducing CAUTI in Hospitals.

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.

Journal Article > Study

Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.

Gardner AK, Abdelfattah K, Wiersch J, Ahmed RA, Willis RE. J Surg Educ. 2015;72:e158-e162.

This study suggests that incorporating error training into curricula may result in better skill retention. Surgical interns were exposed to either a video showing only correct placement of central venous catheters, or one showing both correct placement and errors. Trainees performed similarly on immediate postcourse tests, but the group that included error training performed significantly better one month later.

Journal Article > Study

State-mandated hospital infection reporting is not associated with decreased pediatric health care–associated infections.

Rinke ML, Bundy DG, Abdullah F, Colantuoni E, Zhang Y, Miller MR. J Patient Saf. 2015;11:123-134.

Some states require public reporting of rates of central line–associated bloodstream infections (CLABSI). Investigators did not find differences in CLABSI rates between states with and without public reporting, suggesting that current transparency efforts are not sufficient to improve this safety target.

Journal Article > Study

Influence of the Comprehensive Unit-based Safety Program in ICUs: evidence from the Keystone ICU project.

Hsu YJ, Marsteller JA. Am J Med Qual. 2016;31:349-357.

To determine the impact of the Comprehensive Unit-Based Safety Program (CUSP) on patient safety, this study compared intensive care units participating in the program with units not participating. Although safety culture improved in units with CUSP implementation, the intervention did not reduce incidence of central line–associated bloodstream infections. These findings demonstrate that teamwork training approaches, while helpful, may not be sufficient to augment patient outcomes. Further study characterizing sites that improved versus those that did not may elucidate facilitators and barriers to achieving patient safety goals.

Tools/Toolkit > Multi-use Website

ANA CAUTI Prevention Tool.

Silver Spring, MD: American Nurses Association; 2015.

Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, focuses on promoting nursing behaviors to prevent CAUTIs including decreasing catheter use and improving catheter maintenance.

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