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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.

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 > Commentary

The tension between promoting mobility and preventing falls in the hospital.

Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.

This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.

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.

Newspaper/Magazine Article

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

ISMP Medication Safety Alert! Acute Care Edition. March 23, 2017;22:1-5.

Leadership commitment is important to improving patient safety. This newsletter article reports how leadership involvement in adopting and applying best practices and establishing a learning culture in the organization can achieve lasting medication safety improvements.

Journal Article > Study

Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.

Bursiek AA, Hopkins MR, Breitkopf DM, et al. J Patient Saf. 2017 Mar 7; [Epub ahead of print].

Fall prevention is a critical patient safety activity. This pre–post study of simulation-based team training resulted in higher teamwork scores and lower rates of preventable falls over time. These results lend support to team training as a strategy to improve patient safety.

Journal Article

Quality and Safety in Health Care.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2017.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and patient safety organizations.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

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.

Book/Report

National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.

  • Classic

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

Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.

Journal Article > Review

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

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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.

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

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

Tawfik DS, Sexton JB, Kan P, et al. J Perinatol. 2017;37:315-320.

Burnout has been linked to work dissatisfaction and increased rates of adverse events. This retrospective study found that burnout was prevalent among health care workers in the neonatal intensive care unit setting. In high-volume centers, burnout was correlated with higher rates of health care–associated infections. These results demonstrate the association between burnout and care quality.

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.

Grant > Government Resource

Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.

Rockville, MD: Agency for Healthcare Research and Quality; October 13, 2016. PA-17-007 and PA-17-008.

Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through January 26, 2021 for the R18 funding and March 6, 2021 for the R01 funding.

Journal Article > Study

Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed.

Freedberg DE, Salmasian H, Cohen B, Abrams JA, Larson EL. JAMA Intern Med. 2016;176:1801-1808.

Clostridium difficile diarrhea is a common and highly morbid health care–associated infection. This study demonstrated that when a hospitalized patient receives antibiotics, the next patient who occupies the same hospital bed is at risk for C. difficile infection. This finding highlights the importance of both antibiotic stewardship programs and environmental approaches to infection control.

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