Neuroinvasive Infection in Immunocompromised Hosts: Epidemiologic Investigation of 5 Patients With Acute Myeloid Leukemia.

Background: is a ubiquitous gram-positive rod-shaped bacterium that can cause sepsis and neuroinvasive disease in patients with acute leukemia or neutropenia.

Methods: A single-center retrospective review was conducted to evaluate patients with acute leukemia, positive blood or cerebrospinal fluid test results for , and abnormal neuroradiographic findings between January 2018 and October 2022. Infection control practices were observed, environmental samples obtained, a dietary case-control study completed, and whole genome sequencing performed on environmental and clinical isolates.

Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System.

Background: Nontuberculous mycobacteria are water-avid pathogens that are associated with nosocomial infections.

Objective: To describe the analysis and mitigation of a cluster of infections in cardiac surgery patients.

Design: Descriptive study.

Sources of exposure identified through structured interviews of healthcare workers who test positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2): A prospective analysis at two teaching hospitals.

We interviewed 1,208 healthcare workers with positive SARS-CoV-2 tests between October 2020 and June 2021 to determine likely exposure sources. Overall, 689 (57.0%) had community exposures (479 from household members), 76 (6.

Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis.

Objectives: The aims of the study were to assess a system-based approach to event investigation and analysis-collaborative case reviews (CCRs)-and to measure impact of clinical specialty on strength of action items prescribed.

Methods: A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes.

A SARS-CoV-2 Cluster in an Acute Care Hospital.

Background: Little is known about clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in acute care hospitals.

Objective: To describe the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies.

Design: Descriptive study.

Practice pattern of use of high sensitivity troponin in the outpatient settings.

Background: High-sensitivity troponin assays (hs-Tn) detect lower serum concentrations than prior-generation assays and help guide acute coronary syndrome (ACS) evaluation in emergency departments. Outpatient hs-Tn utilization is not well described.

Hypothesis: Outpatient providers use hs-TnT to triage patients with suspected ACS.

Low Risk of Coronavirus Disease 2019 (COVID-19) Among Patients Exposed to Infected Healthcare Workers.

Many patients are fearful of acquiring coronavirus disease 2019 (COVID-19) in hospitals and clinics. We characterized the risk of COVID-19 among 226 patients exposed to healthcare workers with confirmed COVID-19. One patient may have been infected, suggesting that the risk of COVID-19 transmission from healthcare workers to patients is generally low.

COVID-19 infections among HCWs exposed to a patient with a delayed diagnosis of COVID-19.

We report on COVID-19 risk among HCWs exposed to a patient diagnosed with COVID-19 on day 13 of hospitalization. There were 44 HCWs exposed to the patient before contact and droplet precautions were implemented: of these, 2 of 44 (5%) developed COVID-19 potentially attributable to the exposure.

Closing the Loop with Ambulatory Staff on Safety Reports.

Background: A commonly cited reason among nurses and physicians for not reporting safety events is a perceived lack of feedback from management on filed safety reports. This suggests that the value of a safety reporting system could be improved with a closed-loop feedback system between management and frontline staff on filed safety reports in which feedback was requested.

Methods: Ambulatory staff were surveyed on barriers to reporting to assess this challenge at an academic medical center.

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

Importance: Death due to preventable medical error is a leading cause of death, with varying estimates of preventable death rates (14%-56% of total deaths based on national extrapolated estimates, 3%-11% based on single-centre estimates). Yet, how best to reduce preventable mortality in hospitals remains unknown.

Objective: In this article, we detail lessons learnt from implementing a hospital-wide, automated, real-time, electronic mortality reporting system that relies on the opinions of front-line clinicians to identify opportunities for improvement.

Building an Ambulatory Safety Program at an Academic Health System.

Background: Patient safety has traditionally focused on the inpatient setting; however, there is an increased awareness of ambulatory safety risk. However, successful strategies and programs to mitigate risk in the ambulatory setting are lacking.

Program: In 2012, we started building a multidisciplinary ambulatory safety program at an academic health system.

Safety Culture in the Operating Room: Variability Among Perioperative Healthcare Workers.

Introduction: Safety culture is defined as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine an organization's health and safety management. There is a lack of studies assessing patient safety culture in the perioperative setting.

Objectives: We examined safety culture at a single tertiary care hospital, across all types of surgery, using previously collected data from a validated survey tool.

Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic Medical Center.

Background: Incomplete medication reconciliation has been identified as a source of adverse drug events and a threat to patient safety. How best to measure and improve rates of medication reconciliation in ambulatory care remains unknown.

Methods: An institutional collaborative improvement effort to develop and implement medication reconciliation processes was designed and facilitated across all 148 Brigham and Women's Hospital (Boston) ambulatory specialty practices: 63 underwent a more rigorous approach, a modified approach was undertaken in another 71 specialty practices, and a less intensive approach took place in the 14 primary care practices.

Anticoagulation-associated adverse drug events.

Purpose: Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a 5-year retrospective study at Brigham and Women's Hospital to determine clinical characteristics, types, root causes, and outcomes of anticoagulant-associated ADEs.

Methods: We reviewed all inpatient anticoagulant-associated ADEs, including adverse drug reactions (ADRs) and medication errors, reported at Brigham and Women's Hospital through the Safety Reporting System from May 2004 to May 2009.

Hospital budget implications of substituting dabigatran for warfarin in an anticoagulation service.

The aim of our study was to assess hospital budget implications of substituting dabigatran for warfarin in patients enrolled in a large anticoagulation service. The study population was identified using criteria from randomized controlled trials of dabigatran. We obtained labor costs ($483 per patient) from the hospital's anticoagulation service budget, laboratory costs of international normalized ratio (INR) tests ($267 per patient), and wholesale costs of warfarin 5 mg tablets ($31 per patient) and dabigatran 150 mg capsules ($2464 per patient).

Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study.

Background: Despite existing consensus guidelines, venous thromboembolism (VTE) prophylaxis is underused in high-risk hospitalized patients. The present study evaluated the effects of an electronic alert to the responsible physician in a cohort of hospitalized high-risk patients not receiving VTE prophylaxis.

Methods: The absence of VTE prophylaxis orders in hospitalized patients at high-risk for VTE triggered an electronic alert to the responsible physician.

Adverse drug events in hospitalized cardiac patients.

Little information is available concerning adverse drug events (ADEs) in cardiac patients. Therefore, the investigators report the results of cardiac patients in an ADE surveillance program, with the intent of reducing the frequency of future events. All reported adverse drug reactions and medication errors in cardiac patients over a 5-year period at Brigham and Women's Hospital were reviewed.

Impact of smart infusion technology on administration of anticoagulants (unfractionated Heparin, Argatroban, Lepirudin, and Bivalirudin).

This study reviewed 863 alerts generated from the infusion of anticoagulants in 355 patients from October 2003 to January 2005. Alerts were generated by smart infusion technology pumps and recorded in the devices' memory. The most common alerts were underdose alerts (59.

Infectious complications associated with alemtuzumab use for lymphoproliferative disorders.

Background: Alemtuzumab is an emerging therapy for refractory lymphoproliferative disorders. The associated long-term risks of infection remain poorly defined.

Methods: From July 2001 through December 2003, all patients who received alemtuzumab for the treatment of lymphoproliferative disorders at 1 institution underwent a retrospective evaluation to document infectious complications until death or end of follow-up in October 2004.