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 373 results
Download Selected Citations

Show: 20 | 50 | 100

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 > 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.

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.

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.

  • 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.

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.

Journal Article > Commentary

Antimicrobial stewardship and patient safety.

Zukowski CM. AORN J. 2016;104:354-356.

Antimicrobial stewardship has been highlighted as a strategy to improve antibiotic use in order to reduce hospital-acquired infections. This commentary discusses antimicrobial stewardship teams, their impact in the surgical setting, and the role of nurses in ensuring appropriate use of antibiotics.

Journal Article > Study

Viewing prevention of catheter-associated urinary tract infection as a system: using systems engineering and human factors engineering in a quality improvement project in an academic medical center.

Rhee C, Phelps ME, Meyer B, Reed WG. Jt Comm J Qual Patient Saf. 2016;42:447-471.

Catheter–associated urinary tract infections (CAUTI) lead to preventable harm and cost among hospitalized patients. In this quality improvement program, principles of human factors engineering were applied to reduce CAUTI at an academic medical center. Investigators utilized systems approaches to examine the factors related to CAUTI at their institution, including how the physical layout influenced adherence to best practices. They made changes based on this assessment, such as enhancing access to catheter maintenance supplies across all hospital units. The intervention also used technology (automated electronic health record reminders) and training (asynchronous education on catheter insertion) to augment safe catheter use. This multipronged approach led to a steep reduction in CAUTI at the end of the 3-year project compared to the preintervention period. The authors suggest that their results support the use of human factors engineering to decrease health care–associated infections.

Book/Report

Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report.

Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.

The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.

Web Resource > Multi-use Website

Rory Staunton Foundation for Sepsis Prevention.

135 West 50th Street, Eurotech Suite, 5th Floor, New York, NY.

Sepsis is a serious condition that can be rapidly fatal if it is not promptly diagnosed and treated. This foundation seeks to improve education and awareness of sepsis in the name of a pediatric patient who died when his sepsis was misdiagnosed in the emergency room.

Back to Top