Perceived Value of the Daily Safety Briefing.

A hospital-level daily safety briefing (DSB) is a time for leaders to come together and address recent and upcoming safety challenges in the hospital. As tools to facilitate communication and teamwork, DSBs are important, but their value has not been extensively studied. We studied the value of the DSB by means of a prospective written survey of participants of the DSB at an urban academic medical center.

Statewide Collaborative to Reduce Surgical Site Infections: Results of the Hawaii Surgical Unit-Based Safety Program.

Background: Surgical site infections (SSIs) after colorectal surgery are common, lead to patient harm, and are costly to the healthcare system. This study's purpose was to evaluate the effectiveness of the AHRQ Safety Program for Surgery in Hawaii.

Study Design: This pre-post cohort study involved 100% of 15 hospitals in Hawaii from January 2013 through June 2015.

A Quality Improvement Intervention Reduces the Time to Administration of Stat Medications.

Introduction: The delivery of urgent ("stat") medications to hospitalized children is important for safe quality care. The goal of this study was to evaluate the effect of a set of interventions on the percentage of stat medications administered within 30 minutes of ordering.

Methods: A pre-post study in 2 pediatric units (36 beds) in a private hospital in Saudi Arabia between January 2015 and September 2016.

Reducing preventable harm: observations on minimizing bloodstream infections.

Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates.

Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions.

Background And Objective: Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population.

Methods: Structured literature review of PubMed and clinicaltrials.

Surgical site infection: comparing surgeon versus patient self-report.

Background: To compare the rate of surgical site infection (SSI) using surgeon versus patient report.

Materials And Methods: A prospective observational study of surgical patients in four hospitals within one private health-care system was performed. Surgeon report consisted of contacting the surgeon or staff 30 d after procedure to identify infections.

CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections.

A national collaborative helped many hospitals dramatically reduce central line-associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units.

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.

Background: In 2009, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality; public agencies, including the FDA; and private partners, including the Emergency Care Research Institute and the University HealthSystem Consortium (UHC) Safety Intelligence Patient Safety Organization, sought to form a public-private partnership for the promotion of patient safety (P5S) to advance patient safety through voluntary partnerships. The study objective was to test the concept of the P5S to advance our understanding of safety issues related to ventilator events, to develop a common classification system for categorizing adverse events related to mechanical ventilators, and to perform a comparison of adverse events across different adverse event reporting systems.

Methods: We performed a cross-sectional analysis of ventilator-related adverse events reported in 2012 from the following incident reporting systems: the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, UHC's Safety Intelligence Patient Safety Organization database, and the FDA's Manufacturer and User Facility Device Experience database.

Predicting Which Patients will Likely Benefit from Subglottic Secretion Drainage Endotracheal Tubes: A Retrospective Study.

Background: Subglottic secretion drainage endotracheal tubes (SSD ETTs) have been shown to decrease ventilator-associated pneumonia and are recommended for patients intubated > 48 h or 72 h. However, it is difficult to determine which patients will be intubated > 48 h or 72 h at the time of intubation.

Objective: We attempted to determine which patient characteristics were associated with intubations ≥ 48 h or 72 h in order to guide proper placement of SSD ETTs.

A Tool for the Concise Analysis of Patient Safety Incidents.

Background: Patient safety incidents, sometimes referred to as adverse events, incidents, or patient safety events, are too common an occurrence in health care. Most methods for incident analysis are time and labor intensive. Given the significant resource requirements of a root cause analysis, for example, there is a need for a more targeted and efficient method of analyzing a larger number of incidents.

The prevalence of long QT interval in post-operative intensive care unit patients.

The severity of patient illnesses and medication complexity in post-operative critically ill patients increase the risk for a prolonged QT interval. We determined the prevalence of prolonged QTc in surgical intensive care unit (SICU) patients. We performed a prospective cross-sectional study over a 15-month period at a major academic center.

Effect of altering alarm settings: a randomized controlled study.

Unlabelled: Medical alarm signals are important for alerting clinicians to life-threatening conditions, but the high rate of false alarms can be problematic. Reduction in alarm signals may lead to increased staff responsiveness to alarms and create a quieter environment for patients. The effect of these changes on patient outcomes is uncertain.

On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile.

Background: Central line-associated bloodstream infection (CLABSI) remains one of the most common and deadly hospital acquired infections in the United States. Creating a culture of safety is an important part of healthcare-associated infection improvement efforts; however, few studies have robustly examined the role of safety climate in patient safety outcomes. We applied a pattern-based approach to measuring safety climate to investigate the relationship between intensive care unit (ICU) patient safety climate profiles and CLABSI rates.

What to do with healthcare incident reporting systems.

Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be.

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

Background: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

Methods: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network.

Achieving and sustaining ventilator-associated pneumonia-free time among intensive care units (ICUs): evidence from the Keystone ICU Quality Improvement Collaborative.

Our retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative demonstrated that adult ICUs could achieve and sustain a zero rate of ventilator-associated pneumonia (VAP) for a considerable number of ventilator and calendar months. Moreover, the results highlight the importance of adjustment for ventilator-days before comparing VAP-free time among ICUs.