Articles
Here you will find the entire listing of every article in SafetyShare.
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A | B | C |
D | E | F |
G |
H | I | J | K | L |
M
N | O |
P | Q | R |
S | T |
U | V | W | X | Y | Z
B
Back injury
- Business case for ergonomics program for clinicians (5/05)
- Lifting teams and equipment key to preventing back injuries (3/04)
- Endurance exercises for low back pain hasten return to work (2/04)
- Nurses report frequent back pain - Few using lifting equipment (1/04)
- Premier launches Web resources for preventing back injuries (3/03)
Bar coding and UDI
- Bar-coding surgical sponges reduces risk of loss, researchers find (09/08)
- Congress approves law for FDA to create unique device identification of medical devices - recent survey confirms benefit to patient safety (9/07)
- House members call for unique medical device identification to improve patient safety (5/07)
- Veterans hospitals share experiences with planning, troubleshooting to maximize bedside bar coding (9/04)
- FDA imposes 2006 deadline for bar codes on drugs and blood products (3/04)
Building environment protection and construction issues
- Hospitals aim to reduce noise levels to improve healing, patient satisfaction and reduce error and worker stress (8/07)
- Private room requirement among proposed AIA/FGI guidelines; Comment deadline extended (2/05)
- Radio frequency identification technology emerges to reduce risk of wrong–site surgery (12/04)
- AIA seeks comments on minimum requirements of single rooms for proposed construction guideline (11/04)
- Safety implications of single-bed rooms being addressed in revision of AIA construction guidelines (10/04)
- Risk assessment guidelines for construction reduce infection risks (4/04)
- Patient safety principles drive new hospital design (3/04)
- Green guidelines released for comment (1/04)
- American Institute of Architects answers hospital design and construction questions on Web site (4/02)
Bulletins
(Special SafetyShare bulletins)
- New needlestick prevention brochure from Premier (9/5/07)
- Free admission to Premier educational program: HAI (5/29/07)
- AHRQ Announces Call for Papers for Advances in Patient Safety: New Directions and Alternative Approaches (4/9/07)
- NPSF 2007 Congress: Call for posters, early registration (1/4/07)
- Free audio conference: Infection control surveillance automation (11/17/06)
- Device recall survey (10/20/06)
- Webcast: Better quality can cost less and saves lives (10/2/06)
- Premier Safety Institute Web site: New, updated resources (8/11/06)
- Performance Pays: High quality care cost less and saves lives (6/16/06)
- Free audio conference: Impact of adverse events – Results from Tufts-New England Medical Center study using electronic incident reporting (3/27/06)
- JCAHO clarifies position on alcohol hand sanitizers – foam and gel now permitted in corridors (3/15/06)
- Patient and environmental health and safety (2/16/06)
- NPSF 2006 Congress: Call for posters and early-bird registration (2/7/06)
- CMS/Premier Hospital Quality Incentive Demonstration - Year 1 Results (11/21/05)
- Premier audio conference: SCIP – A National Quality Partnership (10/10/05)
- The safety and quality continuum – using an electronic incident record to aggregate disparate data (9/26/05)
- Key hurricane resources - Links and downloads (9/14/05)
- Premier audio conference: Reduce Length of Stay, Improve Quality with Data and Best Practices (8/4/05)
- Patient safety culture survey tool available in Spanish (7/13/05)
- Premier audio conference: From SIP to SCIP: Preparing for additions to the Surgical Infection Prevention (SIP) measures under the CMS 8th Scope of Work (6/9/05)
- AHRQ's June 6-10 Patient Safety and Health IT Conference (5/24/05)
- Premier audio conference: "Achieving Clinical and Operational Excellence in the Emergency Department" (4/28/05)
- 'Taking Action' - telephone briefing on the AHRQ Hospital Survey on Patient Safety Culture (4/14/05)
- Premier audio conference: IHI 100,000 Lives Campaign (3/30/05)
- Register now for 2005 NPSF Congress: May 4-6, Orlando (3/24/05)
- Premier offers culture survey data tool (3/2/05)
- Free audio conference: Improving patient safety through automated incident/error reporting and root cause analysis (2/23/05)
- Free audio conference: Hardwiring Labor Management for quality, safety, and efficiency (1/25/05)
- February 15 audio conference - safety culture survey (01/14/05)
- NPSF 2005 Congress: Call for posters and early-bird registration (1/03/05)
- Free audio conference: Engaging physicians (12/20/04)
- A safe environment fosters patient safety (11/30/04)
- Hospital Survey on Patient Safety Culture (11/10/04)
- Free audio conference: Performance dashboards (10/26/04)
- Register for 2004 Quality Colloquium, a safety, error reduction education opportunity set for August 22-25 (6/18/04)
- Bulletin: A major win for alcohol hand rub dispenser placement (4/28/04)
- CDC releases full environmental infection control guidelines (12/03)
- FluMist not recommended for healthcare personnel (10/03)
- AHA-ASHE-CDC collaborate with fire safety experts on alcohol-based hand rubs – code changes likely (9/03)
- Premier earns national recognition for environmental leadership efforts (4/03)
- Patient safety awareness week - March 9-15, 2003 (3/03)
- Institute for Healthcare Improvement (IHI) hosting Mini-Series at NPSF Patient Safety Congress (2/03)
- NPSF Patient Safety Congress - March 12-15, 2003 - Register now! (1/03)
- NPSF Patient Safety Congress - March 2003 - Register now! (12/02)
- Patient safety conferences in October (09/02)
- CDC plans broadcasts: Disaster Grants and Immunizations Update (08/09)
- Deadline extended for interactive learning proposals for symposium (06/02)
C
Cell phones
- Mayo study finds cell phones in hospitals safe; but CD players and anti-theft devices may pose certain risks (3/07)
- Newer cell phone devices are safer; distance from critical devices is key (2/07)
CDC - Centers for Disease Control and Prevention
- CDC releases guide for removing microbes from surfaces and devices -- C. difficile, norovirus, and more (12/08)
- 60 percent increase in use of EMR in physicians’ offices since 2001: CDC survey (12/08)
- CDC's NHSN record number of participants driven by state requirements for infection reporting (10/08)
- Respiratory hygiene added to standard precautions in 2007 CDC isolation guidelines (7/07)
- Reductions in drug-resistant bugs and infection are key to selecting isolation methods: CDC's new guideline (11/06)
- CDC advises routine HIV screening for all patients; recommends the "opt-out" approach (10/06)
- Investigation of lapses in tissue screening; CDC offers guidance for patients (6/06)
- CDC, IHI release new tool to increase hand hygiene compliance (4/06)
- Influenza update: New rapid blood test for avian flu; CDC releases first exclusive worker influenza immunization guideline (3/06)
- CDC recommends use of newer antivirals over resistant Rimantadine, Amantadine (1/06)
- CDC updates healthcare TB control guidelines; blood test replaces TB skin test (1/06)
- Influenza vaccination now required in LTC; CDC monitors vaccine supply (10/05)
- Key hurricane resources - Links and downloads (9/14/05)
- CDC's early release of 2005 flu vaccine guidance clarifies role of live-attenuated vaccines in healthcare workers (7/05)
- CDC issues guidance on public reporting of healthcare-associated infections (3/05)
- CDC's National Nosocomial Infections Surveillance (NNIS) reports drop in urinary and bloodstream infections in ICU (1/05)
- Comments for CDC draft isolation guideline due in August (7/04)
- CDC releases new flu vaccine guidelines for children (5/04)
- CDC publishes online workbook on sharps injury prevention (3/04)
- CDC releases draft SARS preparedness plan (11/03)
- AHA-ASHE-CDC collaborate with fire safety experts on alcohol-based hand rubs – code changes likely (9/03)
- IOM recommends CDC assess current smallpox vaccination program plans (6/03)
- CDC issues guidelines on HIPAA implications for public health (5/03)
- CDC's hand hygiene guideline spurs controversy (3/03)
- CDC and military report few serious adverse vaccination events (3/03)
- CDC highlights alcohol-based hand rubs in new guidelines (11/02)
- CDC favors smallpox vaccination of healthcare workers and public (10/02)
- CDC provides West Nile virus resources for clinicians and families (09/02)
- CDC guidelines address antimicrobial catheters and bloodstream infections (09/02)
- CDC plans broadcasts: Disaster Grants and Immunizations Update (08/09)
- Hospital infections pose serious problem; CDC expands monitoring (08/02)
- CDC committee recommends wider access to smallpox vaccine (07/02)
- CDC reports 26 patient infections and one death from contaminated tissue transplants (04/02)
- CMS and CDC launch national Surgical Infection Prevention Project (04/02)
Centers for Medicare and Medicaid (CMS)
- Joint Commission standards become more prescriptive to meet CMS requirements: good news and bad news (01/09)
- CMS begins reduced reimbursement for ten hospital-acquired conditions (10/08)
- CMS expands the list to 10 hospital-acquired conditions for reduced payment (09/08)
- Education critical to implement 2008 CMS hospital-acquired conditions rule (02/08)
Computerized Physician Order Entry (CPOE)
- Bar-coding surgical sponges reduces risk of loss, researchers find (09/08)
- More than $17 million return on investment with CPOE (6/06)
- CPOE reduces some errors, creates others (3/05)
- Multiple studies, Leapfrog confirm need for CPOE balance of physician autonomy and override capabilities (9/04)
- Nearly half of California hospitals plan to implement CPOE (12/03)
Construction
- Rationale for private rooms for patient safety explained (09/08)
- USP issues pharmacy sterile compounding standards; ventilation requirements costly (12/07)
- Patient lift devices, bariatric issues planned for 2010 AIA Guidelines – public invited to comment (6/07)
- New Green Guide launched with tools to build healing healthcare environments (2/07)
- Hospital acoustic design impacts patients and healthcare workers (2/07)
- Automated sprinklers to improve fire safety tied to proposed nursing home rules (12/06)
- Private rooms are the standard for new construction to reduce medical errors and infection risks (7/06)
- Private patient rooms – a new building requirement promotes safety (4/06)
- Special precautions protect high-risk patients during year-long construction project (8/05)
- Premier hospitals work to reduce noise, promote safer patient environment (7/05)
- Nursing input critical for construction planning (6/05)
D
Dental health care
Disclosure
- Fear of malpractice does not affect physician belief that errors should be disclosed (9/06)
- Hospital leaders favor patient disclosure of errors but fear negative impact of public reporting (5/05)
- Premier survey – Malpractice a barrier to disclosure consistent with AHRQ research (8/04)
- Premier releases results of survey on disclosure practices (6/04)
E
Emergency department
- First study showing rapid response teams result in dramatic drop in both hospital-wide mortality and non-ICU code rates (02/08)
- One-third of ED communications are interruptions, contributing to medical error (8/07)
- Empowered ED staff activating cath lab, on-site cardiologists among strategies to reduce AMI door-to-balloon time (12/06)
- Inadequate handoffs, lack of knowledge and excessive workload among contributing factors for missed diagnoses in ED (11/06)
- Emergency response teams reduce cardiac arrest and mortality (10/04)
- Hospital-wide teams, performance metrics and ongoing evaluation improve ED patient flow (10/04)
Emergency preparedness
- Checklist added to pandemic planning resources from HHS, WHO (8/07)
- HHS increases stockpile of vaccine, antivirals, and respiratory protection (12/06)
- Recent hurricanes and blackouts prompt JCAHO to issue alert assessing emergency electrical power system failures (10/06)
- Government stresses need for local and individual disaster plans (5/06)
- Key hurricane resources - Links and downloads (9/05)
- OSHA requests comment on ‘First receivers of victims from mass casualties’ (8/04)
- Severe Acute Respiratory Syndrome (SARS) resurfaces in China (1/04)
- CDC releases draft SARS preparedness plan (11/03)
- September marked by new preparedness efforts, resources (9/03)
- GAO: Future SARS outbreak could overwhelm hospitals (8/03)
- Smallpox vaccine OK’d for monkeypox prevention as broader plan slows (7/03)
Environmental safety
- Premier receives major industry honor for environmental leadership fifth consecutive year (5/07)
- New Green Guide launched with tools to build healing healthcare environments (2/07)
- Automated sprinklers to improve fire safety tied to proposed nursing home rules (12/06)
- Private patient rooms – a new building requirement promotes safety (4/06)
- Premier earns fourth consecutive environmental leadership award (4/06)
- Environmental safety success story – Hospitals reducing mercury (10/05)
- Premier provides 'Executive Scorecard' for environmental assessment (1/05)
- Safety implications of single-bed rooms being addressed in revision of AIA construction guidelines (10/04)
- Premier provides 'Executive Scorecard' for environmental responsibility programs (9/04)
- Patient safety principles drive new hospital design (3/04)
- H2E offers tools to improve environmental purchasing and practices (3/04)
- CleanMed 2004 - the leading environmental event for healthcare (2/04)
- Green guidelines released for comment (1/04)
- JCAHO update- new safety goals, core measures, OR protocols (8/03)
- First-time bans on mercury blood pressure devices (7/03)
- Video - Four one-hour videotapes: Patient, worker, environment, and medication safety (10/02)
Environmentally Preferrable Purchasing (EPP)
- Premier earns fourth consecutive environmental leadership award (4/06)
- Premier provides 'Executive Scorecard' for environmental assessment (1/05)
- Premier provides 'Executive Scorecard' for environmental responsibility programs (9/04)
- H2E offers tools to improve environmental purchasing and practices (3/04)
- CleanMed 2004 - the leading environmental event for healthcare (2/04)
- Green guidelines released for comment (1/04)
EPA - Environmental Protection Agency
Ethics
F
Falls
- Fall prevention success linked to standardized assessment with customized prevention strategies key (8/07)
- Prior falls and gait/balance assessment are key predictor of falls (1/07)
- Falls are leading cause of fatal injury among seniors (12/06)
- The impact of prescription-guided psychotropic medication on the elderly (11/05)
- Falls prevention in the elderly: Impact of medication (8/04)
- JCAHO approves fall prevention 2005 safety goal; Premier provides resources (7/04)
FDA - Food and Drug Administration
- Congress approves law for FDA to create unique device identification of medical devices - recent survey confirms benefit to patient safety (9/07)
- Tissue distributors have a role in safe tissue procurement in new FDA guidance (10/06)
- FDA requests comments on identification of medical devices for safety (9/06)
- FDA issues guidance for safe processing and use of human tissues for grafts (12/04)
- FDA updates data on previously approved 510(k) reprocessed single-use devices (11/04)
- FDA issues additional industry guidance for reuse of single-use devices (6/04)
- FDA issues SARS blood screening advice (10/03)
- FDA expands requirements for reprocessed SUDs (6/03)
- FDA guidance aimed at safeguarding blood from SARS (5/03)
- FDA antibiotic labeling rule address MD role in patient education (3/03)
- FDA issues guidance on West Nile virus blood donor deferral (11/02)
- FDA publishes guidelines on PVC medical devices (10/02)
- FDA investigates dialysis patient deaths (10/02)
- FDA moves to protect patients from contaminated transplant tissue (09/02)
- FDA issues guidance on cellular phone use (09/02)
- FDA alert on infection risks with cochlear implants (08/02)
- FDA holds hearing on mandatory bar code labeling (07/02)
- Concern about vCJD prompts FDA to defer certain blood donors (07/02)
- FDA issues notice on risks of exposure to PVC devices (07/02)
- FDA focuses special Web sites on medical devices and medication errors (06/02)
- FDA updates recommendations on cell phones and electromagnetic compatibility (01/02)
- FDA issues recommendations on blood donors exposed to anthrax or Creutzfeldt Jakob Disease (01/01)
G
Guidelines
- CMS expands the list to 10 hospital-acquired conditions for reduced payment (09/08)
- Respiratory hygiene added to standard precautions in 2007 CDC isolation guidelines (7/07)
- New Green Guide launched with tools to build healing healthcare environments (2/07)
- Reductions in drug-resistant bugs and infection are key to selecting isolation methods: CDC's new guideline (11/06)
- Tissue distributors have a role in safe tissue procurement in new FDA guidance (10/06)
- New guidelines aim to reduce performance measurement workload (2/05)
- FDA issues guidance for safe processing and use of human tissues for grafts (12/04)
- Safety implications of single-bed rooms being addressed in revision of AIA construction guidelines (10/04)
- Comments for CDC draft isolation guideline due in August (7/04)
- First-ever guideline released for clinical management of sepsis (4/04)
- Ear infection treatment guidelines: pain relief before antibiotics (4/04)
- Risk assessment guidelines for construction reduce infection risks (4/04)
H
Hand hygiene
- Patients reluctant to remind providers to wash hands; New CDC video educates patients and staff (09/08)
- Hand hygiene adherence improves with alcohol-based hand gels (02/08)
- Clostridium difficile and hand hygiene techniques: An update and commentary (02/08)
- Regulators agree – Alcohol foam hand rubs dispensed in healthcare hallways as safe as gel (6/07)
- Tubing misconnections, sharps disposal, hand hygiene among safety solutions from WHO (6/07)
- 'Location, location, location': Inconveniently placed dispensers adversely impact hand hygiene (5/07)
- Hand hygiene and glove use improves with convenient dispenser location, interactive education and poster campaign featuring senior staff (2/07)
- CMS issues letter supporting use of alcohol-based surgical skin preps (1/07)
- Drying hands after use of alcohol hand rubs reduces risk of sparks from static (5/06)
- CDC, IHI release new tool to increase hand hygiene compliance (4/06)
- Fire protection agencies agree on permitting hand sanitizers in corridors (11/05)
- Study finds women wash hands more; WHO launches worldwide hand hygiene campaign, 'Clean care is better care' (10/05)
- Ban lifted on use of alcohol-based surgical prep solutions if fire prevention precautions are followed (8/05)
- Alcohol-based hand rubs linked to reduction in infection (6/05)
- OR surgical preps ban raises concerns (5/05)
- Regulators agree on alcohol-based hand rub dispensers in hallways (12/04)
- Electronic monitoring improves hand hygiene; infection rates (4/04)
- VA hospitals take a stand on alcohol hand rub dispensers in hallways (2/04)
- AHA-ASHE-CDC collaborate with fire safety experts on alcohol-based hand rubs – code changes likely (9/03)
- JCAHO, others, agree on use of alcohol-based hand cleaners (5/03)
-
CDC highlights alcohol-based hand rubs in new guidelines
(11/02)
HAI - Healthcare-associated infections
- HHS shares metrics to assess reduction of healthcare-associated infection in newly released plan (01/09)
- New Compendium of strategies for preventing healthcare-associated infections provide practical guidance (10/08)
- Experts agree – No evidence to support antimicrobial-resistant disinfectants or link to resistance in antimicrobial agents (10/08)
- Cleaning of patient rooms, a persistent challenge, prompts innovative methods to evaluate effectiveness (9/08)
Hazardous materials
- Environmental safety success story – Hospitals reducing mercury (10/05)
- Ban lifted on use of alcohol-based surgical prep solutions if fire prevention precautions are followed (8/05)
- Regulators agree on alcohol-based hand rub dispensers in hallways (12/04)
- Number of states with bans on mercury thermometers tops 11 (8/03)
- First-time bans on mercury blood pressure devices (7/03)
- List of pharmaceutical products containing mercury now available (10/02)
- FDA publishes guidelines on PVC medical devices (10/02)
- FDA issues notice on risks of exposure to PVC devices (07/02)
- Radiation disaster guidelines released (07/02)
- Hospitals for Healthy Environment announces mercury and waste reduction (01/02)
Healthcare worker safety
- 24/7 Peer Support Program helps staff deal with emotional impact following adverse event (12/08)
- Needlestick injury rate linked to working conditions and frequency of needle use (8/07)
- Nurse staffing and work hours explored in new safety study (3/06)
- Extended work hours increase intern risk of car crashes (2/05)
- Isolating ICU patients does not reduce MRSA transmission, study finds (2/05)
- All hospitals must now comply with OSHA’s bloodborne pathogen rule (6/04)
- Lifting teams and equipment key to preventing back injuries (3/04)
- Endurance exercises for low back pain hasten return to work (2/04)
- Nurses report frequent back pain - Few using lifting equipment (1/04)
- Premier sponsors free sharps safety audio conference February 11 (1/04)
- FluMist not recommended for healthcare personnel (10/03)
- Multi-dose vials addressed in WHO guideline (9/03)
- AHA-ASHE-CDC collaborate with fire safety experts on alcohol-based hand rubs – code changes likely (9/03)
- Best practices for improving the work environment (8/03)
- JCAHO update- new safety goals, core measures, OR protocols (8/03)
- Back injuries cut by 57 percent, costs by 71 percent through lifting equipment, teamwork (7/03)
- OSHA's bloodborne pathogen violations on the rise (5/03)
- Premier launches Web resources for preventing back injuries (3/03)
- CDC and military report few serious adverse vaccination events (3/03)
- IHI and BMJ launch Web site on quality and safety (3/03)
- Wall chart - Chemical terrorism agents (2/03)
- Latex colored gloves cause confusion among latex-allergic workers (12/02)
- CDC favors smallpox vaccination of healthcare workers and public (10/02)
- Video - Four one-hour videotapes: Patient, worker, environment, and medication safety (10/02)
- Medical resident work hours limited (08/02)
- OSHA extends comment period for TB standard (04/02)
- Debate reopens on occupational TB risks (01/02)
HIPAA - Health Insurance Portability and Accountability Act
I
IHI - Institute for Healthcare Improvement
- IHI announces new "5 Million Lives Campaign"- goals include engagement of the Board of Directors (12/01)
- 122,300 lives saved in IHI Campaign; goal exceeded (6/06)
- CDC, IHI release new tool to increase hand hygiene compliance (4/06)
- New techniques dramatically decrease ICU infections in multiple states; initiatives support IHI's '100,000 lives' campaign (8/05)
- IHI's Donald Berwick appointed honorary knight by Queen Elizabeth II (7/05)
- IHI Announces the "Save 100,000 Lives Campaign" (12/04)
- IHI and BMJ launch Web site on quality and safety (3/03)
- Institute for Healthcare Improvement (IHI) hosting Mini-Series at NPSF Patient Safety Congress (2/03)
Infection control and prevention
- Fewer blood transfusions and shorter length of surgeries linked to lower incidence of surgical infections (01/09)
- Syringe reuse among infection control lapses, leading to 33 outbreaks (01/09)
- Cleaning of patient rooms, a persistent challenge, prompts innovative methods to evaluate effectiveness (09/08)
- Surveyed hospitals: Only 10-30 percent use successful CA-UTI prevention practices (02/08)
- Bloodstream infection rates reduced with chlorhexidine bathing (02/08)
- Premier – Healthcare-associated infection presentations available online (12/07)
- Infection control guidelines released for CMS surveys (12/07)
- Making the business case for preventing hospital-associated infections (9/07)
- Checklist added to pandemic planning resources from HHS, WHO (8/07)
- C. difficile infection rates in hospitalized patients rise; current prevention and control strategies still apply (8/07)
- Social distancing and infection control are basis of pandemic flu guidance for public-home setting; masks and respirators secondary (5/07)
- HHS offers severity index for pandemic flu planning to address home isolation, school closings, work schedules (3/07)
- MRSA elimination – only one solution? (3/07)
- Low ICU nurse staffing increases risk of patient infections (2/07)
- Michigan ICUs reduce catheter-related bloodstream infections to zero for 18 months (1/07)
- Syringe reuse in nuclear pharmacy source of Hepatitis C outbreak (12/06)
- Accountability and staff feedback among the keys to success of BSI and VAP bundles in reducing infection (11/06)
- CDC advises routine HIV screening for all patients; recommends the "opt-out" approach (10/06)
- MRSA increasing as cause of outpatient skin, soft-tissue infections (9/06)
- Provide influenza vaccination to healthcare workers, children ages 2 to 4 and offer to patients; CDC recommends (7/06)
- Strategic National Stockpile expands respirator, mask supplies (7/06)
- Offer influenza vaccination to staff: New JCAHO standard (6/06)
- Antimicrobial skin bathing reduces colonization from resistant organisms (4/06)
- Clostridium difficile rates double; experts debate cause and control measures (3/06)
- Influenza update: New rapid blood test for avian flu; CDC releases first exclusive worker influenza immunization guideline (3/06)
- CDC recommends use of newer antivirals over resistant Rimantadine, Amantadine (1/06)
- JCAHO proposes HCW influenza immunization as new IC standard (1/06)
- Emphasis on healthcare worker influenza vaccination shifts to patient safety; mandatory versus voluntary (12/05)
- Long-awaited national pandemic influenza plan is released (11/05)
- Perioperative oxygen reduces surgical site infections in clinical trial (11/05)
- Multi-institutional collaboration results in 68 percent decline in central line associated bloodstream infections (10/05)
- Influenza vaccination now required in LTC; CDC monitors vaccine supply (10/05)
- New techniques dramatically decrease ICU infections in multiple states; initiatives support IHI's '100,000 lives' campaign (8/05)
- Written reminder prompts removal and reduction in urinary catheter days and related infections (8/05)
- Influenza pandemic among concerns prompting APIC launch of advocacy center and worldwide monitoring for infectious diseases (8/05)
- Pennsylvania first to disclose hospital-acquired infections; methods may provide misleading report (7/05)
- Surgical infections drop with antimicrobial prophylaxis compliance; CMS suspends antimicrobial selection measure, citing shortages and need for consensus (7/05)
- Infection control critical to prevent HCV transmission - lessons from two outbreaks (7/05)
- Legionnaire's cases prompt legislation; traditional prevention methods still apply (7/05)
- Alcohol-based hand rubs linked to reduction in infection (6/05)
- Patient-safety incidents, including infections, rising at U.S. hospitals: Report (6/05)
- Congenital rubella eradication and continued TB decline lauded as U.S. public health successes (5/05)
- Consider sepsis from platelet contamination to reduce fatal outcomes (3/05)
- CDC issues guidance on public reporting of healthcare-associated infections (3/05)
- World-wide Avian influenza a serious concern (3/05)
- Healthcare-associated infections likely to join other public safety/quality data reporting (2/05)
- Isolating ICU patients does not reduce MRSA transmission, study finds (2/05)
- CDC's National Nosocomial Infections Surveillance (NNIS) reports drop in urinary and bloodstream infections in ICU (1/05)
- OSHA ‘s annual fit-testing for TB on hold for now (12/04)
- Control of antibiotics, oxygen, glucose, temperature and razor use reduce risk of surgical-site infection (9/04)
- Illinois law permits organ transplants between HIV patients (8/04)
- Comments for CDC draft isolation guideline due in August (7/04)
- Equipment disinfection lapses place patients at risk of infection (7/04)
- No evidence that vaccines linked to autism, IOM reports (6/04)
- All hospitals must now comply with OSHA’s bloodborne pathogen rule (6/04)
- CDC releases new flu vaccine guidelines for children (5/04)
- Electronic monitoring improves hand hygiene; infection rates (4/04)
- First-ever guideline released for clinical management of sepsis (4/04)
- Global prevention efforts target spread of resistant TB (4/04)
- Ear infection treatment guidelines: pain relief before antibiotics (4/04)
- Risk assessment guidelines for construction reduce infection risks (4/04)
- AHRQ releases interactive pneumonia decision-support tool (3/04)
-
Pediatric vaccine update: Influenza
efficacy and suspension of fourth dose
of pneumococcal vaccine (3/04) - First suspected human spread of bird flu documented in Vietnam (2/04)
- CDC’s influenza infection control guidelines provide prevention tips (1/04)
- JCAHO field review - Infection control standards - Deadline February 12 (1/04)
- Severe Acute Respiratory Syndrome (SARS) resurfaces in China (1/04)
- CDC publishes new dental infection control guidelines (1/04)
- JCAHO 2005 infection control standards approved; Universal protocol resources released (12/03)
- CDC releases draft SARS preparedness plan (11/03)
- Care at teaching hospitals associated with higher complication rates (11/03)
- FDA issues SARS blood screening advice (10/03)
- Hepatitis outbreaks linked to unsafe injection practices (10/03)
- Healthcare-associated infection prevention requires partnerships in infection control, risk management, quality (10/03)
- CDC, AHRQ, NQF guidelines for safety-infection prevention (8/03)
- OSHA deletes ergonomic-related provisions in record keeping rule (8/03)
- GAO: Future SARS outbreak could overwhelm hospitals (8/03)
- Smallpox vaccine OK’d for monkeypox prevention as broader plan slows (7/03)
- FDA expands requirements for reprocessed SUDs (6/03)
- CDC Releases Environmental Infection Control Guidelines (6/03)
- OSHA officially withdraws proposed tuberculosis standard (6/03)
- FDA guidance aimed at safeguarding blood from SARS (5/03)
- JCAHO reviews infection control standards (3/03)
- CDC's hand hygiene guideline spurs controversy (3/03)
- CDC and military report few serious adverse vaccination events (3/03)
- Outbreak associated with contaminated bronchoscopes (2/03)
- IOM calls for smallpox education to supplement vaccination (2/03)
- Deaths from influenza and RSV on the rise in the U.S. (2/03)
- Smallpox vaccination planning underway – some remain wary (1/03)
- CMS rule removes physician order requirement from influenza vaccinations (12/02)
- Legal protection approved for smallpox vaccine adverse reactions (12/02)
- FDA issues guidance on West Nile virus blood donor deferral (11/02)
- Providers could face liability, staff shortages from smallpox inoculation effort (11/02)
- CDC favors smallpox vaccination of healthcare workers and public (10/02)
- DOT’s infectious substance transport rule includes new training requirements (09/02)
- CDC provides West Nile virus resources for clinicians and families (09/02)
- CDC guidelines address antimicrobial catheters and bloodstream infections (09/02)
- FDA alert on infection risks with cochlear implants (08/02)
- Legionnaires’ outbreak reported in Pennsylvania nursing home (08/02)
- Hospital infections pose serious problem; CDC expands monitoring (08/02)
- CDC committee recommends wider access to smallpox vaccine (07/02)
- Concern about vCJD prompts FDA to defer certain blood donors (07/02)
- CDC reports 26 patient infections and one death from contaminated tissue transplants (04/02)
- CMS and CDC launch national Surgical Infection Prevention Project (04/02)
Influenza
- Slow start to flu season leads to lower vaccinations at season mid-point; not too late for flu shots as activity picks up (01/09)
- YouTube, a new medium for flu vaccination message (10/08)
- Nasal and injectable flu vaccine options expanded (10/07)
- Resources and tools from around the world on pandemic flu preparation available on new Web site (10/07)
- Checklist added to pandemic planning resources from HHS, WHO (8/07)
- Social distancing and infection control are basis of pandemic flu guidance for public-home setting; masks and respirators secondary (5/07)
- FDA approves first H5N1 influenza vaccine (5/07)
- HHS offers severity index for pandemic flu planning to address home isolation, school closings, work schedules (3/07)
- Insufficient data prompts HHS to recommend higher level of respiratory protection for care of patients during flu pandemic (11/06)
IOM - Institute of Medicine
- IOM report on mask use provides opportunity to focus on assessment-based respiratory protection (5/06)
- Five years after IOM, consumers remain worried about healthcare safety (12/04)
- IOM panel calls information systems key strategy to improve patient safety (12/03)
- IOM report: Limit nursing hours and enhance culture to improve safety (11/03)
- IOM recommends CDC assess current smallpox vaccination program plans (6/03)
- IOM calls for smallpox education to supplement vaccination (2/03)
- IOM states government should take the lead in improving patient safety (11/02)
J
JCAHO - Joint Commission on Accreditation of Healthcare Organizations
- Joint Commission standards become more prescriptive to meet CMS requirements: good news and bad news (01/09)
- Two year doubling of key quality measures – discharge instructions and pneumococcal screening among the best per JC report (12/08)
- Joint Commission releases safety alert on anticoagulants – a key DVT prevention strategy (10/08)
- DNV joins Joint Commission and AOA for accreditation for CMS payment (10/08)
- Recent hurricanes and blackouts prompt JCAHO to issue alert assessing emergency electrical power system failures (10/06)
- JCAHO warns of IV tubing misconnections; calls for attention to design (6/06)
- JCAHO urges local best practice over prescriptive approach to USP 797 standard for sterile medication prep (4/06)
- JCAHO proposes HCW influenza immunization as new IC standard (1/06)
- Hospital Quality Alliance and JCAHO core measure data show steady hospital improvement (10/05)
- IV free flow pumps, concentrated electrolytes, dropped from 2006 JCAHO Patient Safety Goals (6/05)
- Worker fatigue, surgical fires, multi-dose vials among JCAHO's 2006 proposed patient safety goals (2/05)
- Patient-controlled analgesia (PCA) protocols reduce risks, JCAHO warns (1/05)
- CMS, JCAHO release clarification on AMI measure for angiotensin (12/04)
- JCAHO issues anesthesia awareness alert (11/04)
- CMS and JCAHO reconcile reporting measures (10/04)
- JCAHO 2005 patient safety goals approved; New challenges for medication safety (8/04)
- JCAHO approves fall prevention 2005 safety goal; Premier provides resources (7/04)
- JCAHO releases quality performance reports to the public (7/04)
- JCAHO assesses compliance with USP guidelines on compounding sterile preparations (6/04)
- Quality indicators incorporated into national reports (1/04)
- JCAHO field review - Infection control standards - Deadline February 12 (1/04)
- JCAHO 2005 infection control standards approved; Universal protocol resources released (12/03)
- JCAHO publishes medication abbreviation list (11/03)
- New FAQ: JCAHO clarifies safety goal on infections and hand hygiene (10/03)
- JCAHO update- new safety goals, core measures, OR protocols (8/03)
- JCAHO news: early release of standards, surgical fires alert, and surgical site marking protocol (7/03)
- JCAHO modifies requirements for marking the surgical site (6/03)
- JCAHO, others, agree on use of alcohol-based hand cleaners (5/03)
- JCAHO reviews infection control standards (3/03)
- JCAHO cites link between nursing shortage, negative outcomes (09/02)
- JCAHO issues 2003 National Patient Safety Goals (08/02)
- JCAHO to issue national patient safety goals (07/02)
- JCAHO places moratorium on sentinel event scoring and issues alert on ventilator-related deaths (04/02)
M
Medical device issues
- RFID used to detect retained surgical sponges (9/06)
- FDA requests comments on identification of medical devices for safety (9/06)
- Caution urged for replacement of recalled implantable cardiac defibrillators (ICDs) (6/06)
- JCAHO warns of IV tubing misconnections; calls for attention to design (6/06)
- Diverse causes of IV pump errors - integrated technology is key (6/05)
- Cell phone prohibitions may be waning (3/05)
- Cell phone use within 15 cm distance of ventilators causes malfunction (10/04)
- Positioning and stress ulcer prophylaxis among measures to prevent ventilator-associated pneumonia (10/04)
- Government improves quick access to product recall information (2/04)
- Premier sponsors free sharps safety audio conference February 11 (1/04)
- Consensus guidelines published for reprocessing endoscopes (8/03)
- First-time bans on mercury blood pressure devices (7/03)
- FDA expands requirements for reprocessed SUDs (6/03)
- Outbreak associated with contaminated bronchoscopes (2/03)
- FCC action prompts required registration of telemetry to avoid interference (02/03)
- Group urges FDA not to regulate open but unused single-use devices (1/03)
- All healthcare facilities have device recall policies - not all assign responsibility (1/03)
- Nearly 25 percent of hospitals reuse single use devices (11/02)
- Device manufacturers propose alternatives to bar codes (10/02)
- FDA publishes guidelines on PVC medical devices (10/02)
- Fifteen-fold increase in medical device adverse event reporting prompts FDA to launch pilot project (05/02)
- AHA and hospital groups object to new requirements for reuse of single-use devices (05/02)
- Inadequate response to bronchoscope recall possible cause of patient infections (04/02)
- Patient deaths from medical gas mix-ups prompt FDA to issue advisory (04/02)
Medical errors
- Recent rise in "apology" laws in 36 states protect physicians from malpractice (01/09)
- Fatal medication errors in the home increase three-fold with majority related to interactions with use of alcohol (10/08)
- CMS expands the list to 10 hospital-acquired conditions for reduced payment (09/08)
- Adverse drug event reporting is increasing with a few drugs topping the list; abbreviations during prescribing remain an issue (10/07)
- Anxiety about future errors, reputation and sleeplessness among the top effects on physicians following a medical error (9/07)
- Hospitals aim to reduce noise levels to improve healing, patient satisfaction and reduce error and worker stress (8/07)
- One-third of ED communications are interruptions, contributing to medical error (8/07)
- A combination of paper and computer-based safety reporting systems provides lessons for improving event reporting (6/07)
- AHRQ report: Most adverse drug events in hospitals not caused by errors (5/07)
- NQF updates lists of "safe practices" and "never events" prompting call for hospitals to adopt policy of apologizing to injured patients (12/06)
- Low-cost screening tool useful for detecting adverse events in ICU (11/06)
- Redesign of schedules needed to reduce work hours of interns and associated risks, including needlesticks and medical errors (10/06)
- Technical incompetence responsible for majority of surgical errors (9/06)
- Fear of malpractice does not affect physician belief that errors should be disclosed (9/06)
- Disruptive behavior in operating rooms linked to adverse events (7/06)
- Medical students and residents call for disclosure and more open discussions of errors (7/06)
- Universal Protocol will not prevent all wrong-site surgeries (5/06)
- Medication Reconciliation collaborative shares tools, lessons (5/06)
- States review best methods for adverse event data reporting, analysis, feedback and improvement (3/06)
- Online medical error reporting provides rich safety tracking data; strategies needed to increase reporting by physicians (3/06)
- Lack of communication on patient status at 'hand-off' cited as most common reason for adverse events (1/06)
- First patient safety and quality law encourages medical error reporting (8/05)
- Diverse causes of IV pump errors - integrated technology is key (6/05)
- Managing patient flow increases nurse staffing efficiency, reduces errors (6/05)
- Consider sepsis from platelet contamination to reduce fatal outcomes (3/05)
- ISMP finds incentives for error reporting among medication safety improvements (3/05)
- CPOE reduces some errors, creates others (3/05)
- Nearly half of adverse events in Minnesota's new mandatory reporting register are surgically-related (2/05)
- Harmful drug interactions a risk among elderly in outpatient settings (2/05)
- Radio frequency identification technology emerges to reduce risk of wrong–site surgery (12/04)
- Studies show reducing interns' work hours can reduce serious medical errors (11/04)
- Medication errors with pain pumps more harmful: USP, CAPS alert (11/04)
- Pharmacist-patient interviews can reduce medication errors (10/04)
- Epinephrine label changes needed to prevent medication errors, ISMP warns (9/04)
- ISMP Medication Safety Self-Assessment deadline extended (9/04)
- Premier survey – Malpractice a barrier to disclosure consistent with AHRQ research (8/04)
- Smart infusion pumps reduce risk of potentially life-threatening drug errors (7/04)
- Premier releases results of survey on disclosure practices (6/04)
- Costs estimated from surgical tools left in patients (2/04)
- Best practices for labeling intravenous lines (1/04)
- Adverse events decline with pharmacist participation in medical rounds (1/04)
- Errors discussed more openly at surgical than internal medicine staff meetings (12/03)
- Insulin and heparin among top drugs involved in patient harm (12/03)
Mobile phones
- Cell phone prohibitions may be waning (3/05)
- Cell phone use within 15 cm distance of ventilators causes malfunction (10/04)
- FCC announces bandwidth freeze extension through 2005 (7/04)
- FDA issues guidance on cellular phone use (09/02)
- FDA updates recommendations on cell phones and electromagnetic compatibility (01/02)
Mortality
- Rapid response team shown to significantly reduce mortality (10/07)
- Poor health literacy associated with increased mortality (10/07)
- Decreased infant mortality linked to high-level, high-volume neonatal intensive care units (6/07)
- Administrative data improves risk-adjusted mortality rates by adding POA, lab data (1/07)
- Premier's Perspective data supports beta-blocker use in reducing mortality among high-risk surgical patients: New England Journal of Medicine study (8/05)
- Researchers find intensivists better at predicting mortality than numerical score systems (5/04)
- Premier resources to combat obesity; supports national initiatives (4/04)
- Surgeon-versus-hospital procedure volumes linked to mortality (12/03)
N
Nursing
- Handoffs a significant source of patient harm; interruptions and noise prevent communication of key information (12/08)
- Nurse staffing associated with risk of healthcare associated infections (10/08)
- Higher RN staffing linked to lower risk of healthcare-associated conditions (6/07)
- Community hospitals challenged by 80 percent nursing vacancy rate, lack of critical care beds (5/06)
- Nursing input critical for construction planning (6/05)
- Managing patient flow increases nurse staffing efficiency, reduces errors (6/05)
- Nurses report frequent back pain - Few using lifting equipment (1/04)
- Major change in nursing environment critical to patient safety (12/03)
O
Obesity and bariatrics
- Premier resources to combat obesity; supports national initiatives (4/04)
- Obesity epidemic poses new challenges for providers (11/03)
OSHA - Occupational Safety and Health Administration
- OSHA requires blunt-tip suture needles for surgery (5/07)
- OSHA ‘s annual fit-testing for TB on hold for now (12/04)
- OSHA requests comment on ‘First receivers of victims from mass casualties’ (8/04)
- Sharps safety - OSHA issues fewer sharps citations (2/04)
- OSHA deletes ergonomic-related provisions in record keeping rule (8/03)
- OSHA officially withdraws proposed tuberculosis standard (6/03)
- OSHA's bloodborne pathogen violations on the rise (5/03)
- New look for OSHA online resources (09/02)
- OSHA begins random inspections following needlestick injuries (08-02)
- OSHA prohibits needle removal and phlebotomy tube holder reuse (06/02)
- OSHA releases ergonomic plan and eTools; Nursing homes targeted for initial inspections (05/02)
- OSHA extends comment period for TB standard (04/02)
- OSHA delays enforcement of new recordkeeping rule (01/02)
P
Patient safety - general
- Wrong site surgeries, foreign objects left in body comprise 32 percent of adverse events reported to MN health department (02/09)
- Preoperative psychometric warm-up exercises reduce surgical errors: Simulated study (02/09)
- AMI mortality among women greater than men; linked to delayed diagnosis and treatment (01/09)
- 79 percent increase in pressure ulcers in past decade: AHRQ (01/09)
- Two-stage review dramatically increases accuracy of IHI Global Trigger Tool in identifying adverse events (12/08)
- Three out of four patients do not understand ED discharge instructions (10/08)
- Color-coded wristbands moving toward a national standard (09/08)
- Root cause analyses explain why and how events occur; role in prevention unclear (09/08)
- Patients reluctant to remind providers to wash hands; New CDC video educates patients and staff (09/08)
-
Hospital boards benefit from safety dashboards that track system-wide improvement
(02/08) - Olympic theme song reminds staff to turn patients, prevent pressure ulcers (12/07)
- AHRQ report – 10-year steady decline in inpatient mortality (12/07)
- Color-coded patient ID wristbands – the good news and bad news (9/07)
- Harvard "Patient Safety Imperative" – Course for clinicians in October 2007 (9/07)
- Electronic health record cost effective in ambulatory care (8/07)
- Online video training increases compliance with sterile practices during central venous catheter insertion (8/07)
- Tubing misconnections – Better technology needed to eliminate risk (7/07)
- Surgical "time-out" expanding as a performance improvement tool (7/07)
- AHRQ releases safety culture survey benchmarking data from 382 hospitals; results show strong teamwork but room for improvement with handoffs (5/07)
- Nearly half of adverse event reported in Minnesota involved surgery - retained objects and wrong-site surgery (3/07)
- Nursing home resident safety culture scores indicate less developed safety culture - high RN staffing levels associated with higher culture scores (3/07)
- National Patient Safety Initiative launched to provide free electronic prescribing to physicians (2/07)
- WHO global initiative focuses on specific patient safety problems (1/07)
- One-third of wrong-site surgeries not prevented by current "site verification" protocols (11/06)
- A business case for improved patient safety for hospitals and CMS (11/06)
- CMS proposes programs to improve physician-hospital collaboration (10/06)
- Prescription drug warning labels often misunderstood: study (9/06)
- Perceptions of OR teamwork vary among caregiver role (6/06)
- Investigation of lapses in tissue screening; CDC offers guidance for patients (6/06)
- Experts caution rigid interpretation of FDA guidance on bed safety; call patient assessment 'key' (5/06)
- Survey on status of patient safety systems shows mixed results (1/06)
- Unplanned post-op admissions to ICU validated as a patient safety indicator (1/06)
- IHI offers leadership guide for patient safety (11/05)
- First patient safety and quality law encourages medical error reporting (8/05)
- Harvard Patient Safety course for clinicians: Boston, October 20-21, 2005 (8/05)
- AHRQ compendium addresses safety culture through hospital design (7/05)
- Patient-safety incidents, including infections, rising at U.S. hospitals: Report (6/05)
- IV free flow pumps, concentrated electrolytes, dropped from 2006 JCAHO Patient Safety Goals (6/05)
- OR surgical preps ban raises concerns (5/05)
- Deep-vein thrombosis reduced with computer alerts (5/05)
- CMS Web site for consumers compares hospital quality performance (5/05)
- Premier offers customized data tool as companion to AHRQ patient safety culture survey; additional audio conferences scheduled (3/05)
- Worker fatigue, surgical fires, multi-dose vials among JCAHO's 2006 proposed patient safety goals (2/05)
- Isolating ICU patients does not reduce MRSA transmission, study finds (2/05)
- Studies find CPR often performed incorrectly by healthcare workers (2/05)
- Public report card rankings may affect decisions on surgery (1/05)
- Selected AHRQ patient safety indicators apply to pediatric hospitals (1/05)
- Patient-controlled analgesia (PCA) protocols reduce risks, JCAHO warns (1/05)
- IHI Announces the "Save 100,000 Lives Campaign" (12/04)
- Five years after IOM, consumers remain worried about healthcare safety (12/04)
- Radio frequency identification technology emerges to reduce risk of wrong–site surgery (12/04)
- Emergency response teams reduce cardiac arrest and mortality (10/04)
- CMS and JCAHO reconcile reporting measures (10/04)
- Patient fall rates drop 20 percent using innovative prevention strategies (10/04)
- Falls prevention in the elderly: Impact of medication (8/04)
- Premier survey – Malpractice a barrier to disclosure consistent with AHRQ research (8/04)
- Harvard course for clinicians – Tools, techniques for improving safety, Boston, October 25-26, 2004 (8/04)
- U.S. information technology plan includes electronic health records (8/04)
- Longer nursing shifts linked to patient errors (7/04)
- Very young and poor at higher risk of medical errors (7/04)
- RAND Corporation: follow-up report on quality (7/04)
- FDA issues additional industry guidance for reuse of single-use devices (6/04)
- ISMP survey: Workplace intimidation affects patient safety (5/04)
- Leapfrog endorses NQF’s safe practice measures, releases assessment survey (5/04)
- Free Webcast program on improving ICU safety and culture (5/04)
- First-ever guideline released for clinical management of sepsis (4/04)
- Global prevention efforts target spread of resistant TB (4/04)
- MRI projectile object injury underscores need for all-staff training (3/04)
- More nurses lead to improved patient outcomes (3/04)
- Patient safety principles drive new hospital design (3/04)
- Voluntary hospital quality data project linked to reimbursement (2/04)
- Costs estimated from surgical tools left in patients (2/04)
- Government improves quick access to product recall information (2/04)
- Best practices for labeling intravenous lines (1/04)
- JCAHO field review - Infection control standards - Deadline February 12 (1/04)
- Surgeon-versus-hospital procedure volumes linked to mortality (12/03)
- IOM panel calls information systems key strategy to improve patient safety (12/03)
- Major change in nursing environment critical to patient safety (12/03)
- Hastings Center: Discussion of patient safety ethics essential (12/03)
- JCAHO publishes medication abbreviation list (11/03)
- Obesity epidemic poses new challenges for providers (11/03)
- IOM report: Limit nursing hours and enhance culture to improve safety (11/03)
- Greater surgical risks seen in physicians’ offices (11/03)
- Care at teaching hospitals associated with higher complication rates (11/03)
- New FAQ: JCAHO clarifies safety goal on infections and hand hygiene (10/03)
- NQF to publish measures of nursing care; ‘nursing education impacts care’ (10/03)
- FDA issues SARS blood screening advice (10/03)
- Litigation stifles hospitals' efforts to improve patient safety (9/03)
- Patients’ satisfaction linked to staff attitudes, skills (9/03)
- Bar coding, CPOE top two technologies to improve patient safety (9/03)
- Communications as part of medical school curriculum (9/03)
- Multi-dose vials addressed in WHO guideline (9/03)
- JCAHO update- new safety goals, core measures, OR protocols (8/03)
- HHS details plan that promotes national electronic records by 2004 (8/03)
- Litigation on mold-related health effects questioned (8/03)
- Premier, HHS Medicare demonstration project offers hospitals incentives to provide high quality care (7/03)
- Funding, lack of clinical data standards are top barriers to implementing IT for safety (7/03)
- First-time bans on mercury blood pressure devices (7/03)
- Nearly 1000 hospitals join quality performance reporting initiative of AHA, CMS and others (6/03)
- NQF endorses 30 patient safety practices (6/03)
- Lack of CPOE and provider-patient communication linked to outpatient ADEs (6/03)
- JCAHO modifies requirements for marking the surgical site (6/03)
- FDA guidance aimed at safeguarding blood from SARS (5/03)
- ECRI issues special report on IV infusion pumps (5/03)
- Most hospitals meet JCAHO 2003 safety goals; prohibited abbreviation biggest challenge (5/03)
- Premier launches Web resources for preventing back injuries (3/03)
- IHI and BMJ launch Web site on quality and safety (3/03)
- CDC's hand hygiene guideline spurs controversy (3/03)
- NQF releases final safety practices and quality measures (3/03)
- Adverse events common after hospital discharge (3/03)
- CMS issues final quality assessment and performance improvement standards (2/03)
- Deaths from influenza and RSV on the rise in the U.S. (2/03)
- Emergency surgery, heavier body weight are risk factors for retained instruments (2/03)
- Physicians, public agree on medical error importance- differ on reduction strategies (1/03)
- Effort underway for reporting quality data consistent with new IOM report (1/03)
- ICU physician specialists help reduce mortality and length of stay (12/02)
- GAO finds no increased risk in ambulatory-based endoscopy (12/02)
- IOM states government should take the lead in improving patient safety (11/02)
- Poster deadline nears for 2003 NPSF Patient Safety Congress (11/02)
- Video - Patient education on adverse medical events (10/02)
- Video - Four one-hour videotapes: Patient, worker, environment, and medication safety (10/02)
- JCAHO cites link between nursing shortage, negative outcomes (09/02)
- FDA moves to protect patients from contaminated transplant tissue (09/02)
- Patient safety conferences in October (09/02)
- JCAHO issues 2003 National Patient Safety Goals (08/02)
- Transport of endoscopes in carrying cases poses contamination risk (08/02)
- JCAHO to issue national patient safety goals (07/02)
- Proposed legislation would promote voluntary reporting of medical errors (07/02)
- Concern about vCJD prompts FDA to defer certain blood donors (07/02)
- New book documents serious quality gaps (06/02)
- AHRQ study links hospital nurse staffing and patient outcomes (06/02)
- High volume of surgical procedures linked to reduction in surgical mortality risk (05/02)
- JCAHO places moratorium on sentinel event scoring and issues alert on ventilator-related deaths (04/02)
- FDA issues recommendations on blood donors exposed to anthrax or Creutzfeldt Jakob Disease (01/01)
- Reports of wrong site surgery on the rise (01/02)
Patient safety - interventions
- Algorithm for selecting patient safety practices considers prevalence, cost, degree of complexity (09/08)
Patient safety - medication safety
- Adverse drug event reporting is increasing with a few drugs topping the list; abbreviations during prescribing remain an issue (10/07)
- Wide variability of medication container labels increases risk of error (10/07)
- ISMP targets anticoagulation safety with FMEA tool (2/07)
- Consumer partnership assures success in reducing antibiotic use and proper disposal (3/06)
- Key to safe insulin use: Top management commitment, resources, and a link to culture of safety efforts (1/06)
- Clinical Decision Support - paper, electronic support systems supplement education to reduce inappropriate antimicrobial prescribing in outpatient settings (12/05)
- Poor communication a major contributor to medication reconciliation errors: USP (12/05)
- Pharmacists suggest single entry for medication vials with latex as best practice (10/05)
- ADEs in long-term care - heparin and psychotropics biggest culprits (6/05)
- ISMP finds incentives for error reporting among medication safety improvements (3/05)
- Role of biologic rhythm in medication safety for women among AHRQ research featured online (3/05)
- Harmful drug interactions a risk among elderly in outpatient settings (2/05)
- Patient-controlled analgesia (PCA) protocols reduce risks, JCAHO warns (1/05)
- Medication errors with pain pumps more harmful: USP, CAPS alert (11/04)
- Pharmacist-patient interviews can reduce medication errors (10/04)
- Standardized discharge checklist for medications lowers mortality and readmission rates (10/04)
- JCAHO 2005 patient safety goals approved; New challenges for medication safety (8/04)
- Harvard course for clinicians – Tools, techniques for improving safety, Boston, October 25-26, 2004 (8/04)
- JCAHO approves fall prevention 2005 safety goal; Premier provides resources (7/04)
- Smart infusion pumps reduce risk of potentially life-threatening drug errors (7/04)
- No evidence that vaccines linked to autism, IOM reports (6/04)
- CMS Surgical Infection Prevention Project issues antimicrobial prophylaxis advisory (6/04)
- FDA imposes 2006 deadline for bar codes on drugs and blood products (3/04)
- Pediatric vaccine update: Influenza
efficacy and suspension of fourth dose
of pneumococcal vaccine (3/04) - Government improves quick access to product recall information (2/04)
- Best practices for labeling intravenous lines (1/04)
- Adverse events decline with pharmacist participation in medical rounds (1/04)
- Errors discussed more openly at surgical than internal medicine staff meetings (12/03)
- Insulin and heparin among top drugs involved in patient harm (12/03)
- HHS details plan that promotes national electronic records by 2004 (8/03)
- FDA expands requirements for reprocessed SUDs (6/03)
- CDC and military report few serious adverse vaccination events (3/03)
- FDA antibiotic labeling rule address MD role in patient education (3/03)
- USP MEDMARX reports highlight top drug error risks -- insulin, pediatric patients, and ED (2/03)
- Overdose of oncology drug prompts ISMP alert (1/03)
- FDA investigates dialysis patient deaths (10/02)
- Poor labeling contributes to acetaminophen overdoses (09/02)
- FDA holds hearing on mandatory bar code labeling (07/02)
- Insulin, heparin, and morphine top drugs associated with errors (06/02)
- ISMP provides tips on reducing overdose from patient-controlled analgesia (06/02)
- Patient education resources on preventing medical errors (05/02)
- Few hospitals have computerized physician order entry, but many plan to implement (01/02)
Q
Quality of care
- Quality of care measure for heart attack patients retired by CMS (01/09)
- Algorithm for selecting patient safety practices considers prevalence, cost, degree of complexity (09/08)
- CABG mortality rates improve despite decreasing volume (09/08)
- Root cause analyses explain why and how events occur; role in prevention unclear (09/08)
- Temporary, supplemental nurses do not adversely impact on quality and safety of care (10/07)
- Unconscious racial bias influences clinical decision making (10/07)
- Premier & Wye River Group launch best practices Web site on "Leading healthy communities" (9/07)
- New Jersey hospitals reduce pressure ulcers by 70 percent through collaboration (9/07)
- Harvard "Patient Safety Imperative" – Course for clinicians in October 2007 (9/07)
- Online video training increases compliance with sterile practices during central venous catheter insertion (8/07)
- Increased transparency of healthcare quality and cost improves care and empowers patients (7/07)
- Upcoming 2007 Quality Colloquium focuses on developing a safety action plan (7/07)
- Premier seeks entries for 16th annual Cares Award for innovative programs to improve the health of the medically underserved (6/07)
- Premier, CMS extend P4P demonstration project; three-year extension includes new incentive models to improve quality (3/07)
- Patient discharge summaries not available for outpatient physicians two thirds of the time (3/07)
- Study confirms that safety culture varies across ICUs in a single hospital (2/07)
- Administrative data improves risk-adjusted mortality rates by adding POA, lab data (1/07)
- Technology, nurse-staffing ratio associated with high quality performance (1/07)
- Bush signs law requiring study on payment for 'never event' (1/07)
- Empowered ED staff activating cath lab, on-site cardiologists among strategies to reduce AMI door-to-balloon time (12/06)
- NQF updates lists of "safe practices" and "never events" prompting call for hospitals to adopt policy of apologizing to injured patients (12/06)
- New Web site compares quality ratings and cost for all types of healthcare (10/06)
- U.S. healthcare system scores poorly (10/06)
- Pay-for-performance recommended in new report (10/06)
- Restricting duty hours improves quality of life for surgical residents; attending surgeons concerned with continuity of care (7/06)
- Regionalize ER services: IOM recommendation to relieve fragmented care (7/06)
- Performance pays: Premier-CMS announce high quality care costs less and saves lives (6/06)
- Upcoming 2006 Quality Colloquium focuses on patient safety, error reduction (6/06)
- Board of directors' engagement in quality linked to improved hospital performance (5/06)
- CMS updates Hospital Compare quality data (4/06)
- States review best methods for adverse event data reporting, analysis, feedback and improvement (3/06)
- Premier Safety Institute launches Web site on Culture of Patient Safety (3/06)
- Fairview Healthcare Services improves patient and physician satisfaction using Six Sigma (1/06)
- SCIP publishes measurement specifications and additional tools (1/06)
- CMS/Premier Pay-for-Performance produces quality improvements among nation's hospitals (11/05)
- Final measures released for CMS Surgical Care Improvement Project (11/05)
- HCAHPS patient satisfaction survey released for comment (11/05)
- SCIP – A National Quality Partnership audio conference (10/05)
- Hospital Quality Alliance and JCAHO core measure data show steady hospital improvement (10/05)
- First patient safety and quality law encourages medical error reporting (8/05)
- AHA Quest for Quality Prize honors leadership in quality, safety (8/05)
- Upcoming 2005 Quality Colloquium focuses on patient safety, error reduction (7/05)
- Premier - CMS Pay-for-Performance demo reports quality and safety improvements (6/05)
- Public reporting of quality data - good news and bad news (5/05)
- CMS Web site for consumers compares hospital quality performance (5/05)
- Consider sepsis from platelet contamination to reduce fatal outcomes (3/05)
- ISMP finds incentives for error reporting among medication safety improvements (3/05)
- CPOE reduces some errors, creates others (3/05)
- Premier offers customized data tool as companion to AHRQ patient safety culture survey; additional audio conferences scheduled (3/05)
- Healthcare-associated infections likely to join other public safety/quality data reporting (2/05)
- Studies find CPR often performed incorrectly by healthcare workers (2/05)
- Public report card rankings may affect decisions on surgery (1/05)
- Electronic records and monitoring performance may explain higher quality scores in VA hospitals (1/05)
- NQF selects priorities for improving the quality of healthcare in America (1/05)
- IHI Announces the "Save 100,000 Lives Campaign" (12/04)
- Leapfrog survey reveals need for improvement in NQF (12/04)
- Radio frequency identification technology emerges to reduce risk of wrong–site surgery (12/04)
- Hospital nurse performance measures released by NQF (12/04)
- CMS SIP project expands into SCIP to include other surgical complications (11/04)
- U.S. information technology plan includes electronic health records (8/04)
- Quest for Quality nominations being accepted (8/04)
- RAND Corporation: follow-up report on quality (7/04)
- JCAHO releases quality performance reports to the public (7/04)
- Medicare payments linked to reporting hospital quality performance data (6/04)
- Premier study indicates compliance with CABG protocols improves outcomes, reduces cost (5/04)
- New HHS post to facilitate implementing electronic health records (5/04)
- First-ever guideline released for clinical management of sepsis (4/04)
- End-of-life care varies greatly among hospitals (4/04)
- Voluntary hospital quality data project linked to reimbursement (2/04)
- Volume not best predictor of quality of care in some patients (2/04)
- Quality indicators incorporated into national reports (1/04)
- Adverse events decline with pharmacist participation in medical rounds (1/04)
- IOM panel calls information systems key strategy to improve patient safety (12/03)
- CDC, AHRQ, NQF guidelines for safety-infection prevention (8/03)
- Best practices for improving the work environment (8/03)
- Premier, HHS Medicare demonstration project offers hospitals incentives to provide high quality care (7/03)
- RAND Survey: 50 percent of Americans receive optimal care for common conditions (7/03)
R
Recalls
Reprocessing
- Syringe reuse in nuclear pharmacy source of Hepatitis C outbreak (12/06)
- FDA updates data on previously approved 510(k) reprocessed single-use devices (11/04)
- FDA issues additional industry guidance for reuse of single-use devices (6/04)
Root cause analysis
S
Safety culture
- Premier & Wye River Group launch best practices Web site on "Leading healthy communities" (9/07)
- Nursing home resident safety culture scores indicate less developed safety culture - high RN staffing levels associated with higher culture scores (3/07)
- Harvard Patient Safety course for clinicians: Boston, October 23-24, 2006 (9/06)
- Study: Hospital safety culture is local and influenced by department-specific safety policies (4/06)
- AHRQ seeks safety culture survey data - new benchmarking initiative (4/06)
- Premier Safety Institute launches Web site on Culture of Patient Safety (3/06)
- Key to safe insulin use: Top management commitment, resources, and a link to culture of safety efforts (1/06)
- AHRQ compendium addresses safety culture through hospital design (7/05)
SCIP
Sharps injury prevention
- Needlestick injury rate linked to working conditions and frequency of needle use (8/07)
- Nearly all surgical residents sustain needlestick injuries; culture change recommended to improve reporting (7/07)
- Tubing misconnections, sharps disposal, hand hygiene among safety solutions from WHO (6/07)
- OSHA requires blunt-tip suture needles for surgery (5/07)
- Surgery with non sharp devices and techniques is feasible: Journal report (7/06)
- Success noted in adoption of sharps injury prevention devices; but gaps remain (12/05)
- Smart infusion pumps reduce risk of potentially life-threatening drug errors (7/04)
- First online sharps injury prevention course - Touro University (6/04)
- CDC publishes online workbook on sharps injury prevention (3/04)
- Sharps safety - OSHA issues fewer sharps citations (2/04)
- Premier sponsors free sharps safety audio conference February 11 (1/04)
- Hepatitis outbreaks linked to unsafe injection practices (10/03)
- OSHA's bloodborne pathogen violations on the rise (5/03)
- Outbreaks of hepatitis C linked to needle reuse (10/02)
- Premier joins stakeholders in responding to FDA on sharps devices (10/02)
- New look for OSHA online resources (09/02)
- OSHA begins random inspections following needlestick injuries (08-02)
- Needlesticks linked to staffing levels of nurses (06/02)
- OSHA prohibits needle removal and phlebotomy tube holder reuse (06/02)
- Frontline workers identify performance characteristics for sharps safety devices (05/02)
- OSHA delays enforcement of new recordkeeping rule (01/02)
- Inspection procedures for bloodborne pathogen rule revised (01/02)
Staffing
- Decreased ICU nurse staffing increases healthcare-associated infections (12/07)
- Temporary, supplemental nurses do not adversely impact on quality and safety of care (10/07)
- Staffing levels linked to increase in VAP rates in ICU (8/07)
- Higher RN staffing linked to lower risk of healthcare-associated conditions (6/07)
- Nursing home resident safety culture scores indicate less developed safety culture - high RN staffing levels associated with higher culture scores (3/07)
- Low ICU nurse staffing increases risk of patient infections (2/07)
- Technology, nurse-staffing ratio associated with high quality performance (1/07)
- Inadequate handoffs, lack of knowledge and excessive workload among contributing factors for missed diagnoses in ED (11/06)
- Redesign of schedules needed to reduce work hours of interns and associated risks, including needlesticks and medical errors (10/06)
- Consensus guideline cites low cost, low risk, improved outcomes when using rapid response teams (10/06)
- Shortage of critical care specialists impacts on ICU patient care (7/06)
- Community hospitals challenged by 80 percent nursing vacancy rate, lack of critical care beds (5/06)
- Nurse staffing and work hours explored in new safety study (3/06)
- Extended work hours increase intern risk of car crashes (2/05)
- Hospital nurse performance measures released by NQF (12/04)
- As the number of workers per manager increases, employee engagement decreases: Fairview study (11/04)
- More studies needed before mandating minimum nurse-patient ratios (9/04)
- More nurses lead to improved patient outcomes (3/04)
- Major change in nursing environment critical to patient safety (12/03)
- IOM report: Limit nursing hours and enhance culture to improve safety (11/03)
Success stories
- Premier & Wye River Group launch best practices Web site on "Leading healthy communities" (9/07)
- New Jersey hospitals reduce pressure ulcers by 70 percent through collaboration (9/07)
- Premier recognizes its Award for Quality honorees (6/03)
- H2E honors healthcare organizations for environmental leadership programs (5/03)
- First environmentally green hospital planned in Pittsburgh (2/03)
- SSM Health Care wins the Baldrige Quality Award: a healthcare "first" (1/03)
U
UDI
Universal surgical protocol (USP)
- JCAHO urges local best practice over prescriptive approach to USP 797 standard for sterile medication prep (4/06)
- JCAHO assesses compliance with USP guidelines on compounding sterile preparations (6/04)
- JCAHO 2005 infection control standards approved; Universal protocol resources released (12/03)
V
Veteran Affairs
- Majority of inpatient suicides from hanging and cutting; key to prevention is removal of doors and sharps (12/08)
- Study shows NSQIP applicable to both VA and private sector hospitals, paving the way for national comparative system (12/08)