Patient Safety

These resources from the Centers for Disease Control and Prevention (CDC) are aimed at mitigating health care-associated infections (HAIs), including a toolkit for prevention and response across diverse health care settings.

The Patient Safety Initiative from the American Hospital Association is a collaborative, data-driven effort that gives hospitals and health systems a strong voice in the national conversation around health care safety, and tells the hospital and health system patient safety story.

This document, prepared by Compass HQIC, highlights the tools and resources available in the Centers for Disease Control and Prevention's Project Firstline campaign, including partner-developed resources and an on-demand overview course where listeners can learn how to use the materials.

Incidence of surgical site infections declined at multiple hospitals across six states by 32.8% for some procedures after Phoenix-based Banner Health introduced a comprehensive surgical site infection prevention bundle, which included a focus on a surgical antimicrobial prophylaxis.

This podcast from the Society of Critical Care Medicine discusses the links among patient safety, workforce retention and how the COVID-19 pandemic shifted the landscape. It also explores effective staff retention strategies that can impact patient care and enhance the resilience of health care organizations.

The main culprits behind postoperative infections could be the bacteria already present on the patient's skin, according to a study conducted at the University of Washington in Seattle and published in "Science Translational Medicine." The bacterial strains and the types of antibiotic resistance involved in the infections are already present in the patient before the operation and are not acquired during hospitalization.

This podcast from the National Pressure Injury Advisory Panel discuss how N95 masks were protecting, but also causing facial pressure injuries to the nurses on the frontlines during the COVID-19 pandemic.

Small patient volumes in rural hospitals often distort quality data. By employing innovative methods to communicate low-frequency patient safety events that reflect these small volumes, we can more accurately share our safety story and highlight the outstanding work done in rural hospitals. The Convergence Health Infrequent Events Calculator can transform your data, offering insights that go beyond a run chart to effectively convey your quality and patient safety results.

Sepsis remains the leading cause of hospitalization and hospital mortality, contributing to over a third of hospital deaths. You can work towards reducing sepsis mortality one week at a time through Telligen’s “call to action” series. These action items will empower the use of data to understanding sepsis cases at your facility, support collaboration, increase awareness of evidence-based practices for sepsis prevention, and engage patients and families.

The Centers for Disease Control and Prevention (CDC) partnered with Telligen to highlight the Target, Assess, Prevent (TAP) strategy as a quality improvement framework that uses data to prevent hospital-acquired infections (HAI).

This brief provides an introduction to health care coalitions (HCCs) and how they can serve as a resource for Critical Access Hospitals (CAHs) and State Flex Programs (SFPs) to improve emergency response capacity in rural communities.

This comprehensive guide from Telligen focuses on the surgical continuum of care to assist hospitals and surgical care teams in examining surgical workflows, identifying practice gaps, and implementing best practices to prevent surgical site infections (SSIs), post-operative pulmonary embolism (PE) and/or deep-vein thrombosis (DVTs).

More than 560,000 patients develop CAUTI each year, leading to extended hospital stays, increased health care costs, and patient morbidity and mortality. RNs can play a major role in reducing CAUTI rates to save lives and prevent harm, and this streamlined clinical tool from the American Nurses Association can help.

Project Firstline’s resources are easy to use and can be integrated into existing infection control training programs. Whether you have 5 minutes or 30 minutes, you can lead an effective infection control training with your team.

This report from ECRI is designed to help health care organizations set priorities by describing potential issues and providing action steps that may minimize the occurrence of adverse events. The issues identified are based on data from its patient safety organization, root cause analysis reviews, research requests and expert opinion.

This patient safety and quality improvement toolkit from Eastern US Quality Improvement Collaborative provides strategies to engage frontline staff in quality improvement efforts, garner leadership support and develop a culture of safety through a unit-based approach.

This article in the Journal of the American Medical Association discusses the evidence and appropriate strategies used in the prevention of surgical site infections.

The simple act of tooth brushing at least once per day can lower a patient's risk of getting infected with hospital-acquired pneumonia, according to a study published in the Journal of the American Medical Association. Daily tooth brushing was also linked to patients having a shorter duration of mechanical ventilation, a shorter length of stay in the ICU and lower ICU mortality.

This webinar by the Great Plains Quality Innovative Network provides an overview of the terms related to drug-related harm, the scope of the problem, risk factors, prevention strategies and available resources.

This study published in the Annals of the American Thoracic Society researched the benefits and harms of shortening time-to-antibiotics for sepsis, concluding that the impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.

This webinar provides an overview of the different types of urinary tract infections (UTIs), including risk factors, symptoms, diagnosis and treatment options.

Doxycycline is associated with a lower risk of Clostridioides difficile infection (CDI) compared to azithromycin when used for atypical coverage in community-acquired pneumonia (CAP).

The strategies and tactics highlighted in this resource from the American Hospital Association are used by hospitals to reduce healthcare-associated infections and improve their infection prevention and control efforts.

This recorded presentation defines chronic obstructive pulmonary disease (COPD) and shares resources to support patients in managing this disease. Kim Jungkind, a quality improve specialist with the TMF Innovation Network, also provides ideas for reducing COPD readmissions.

This presentation discusses strategies and solutions for reducing adverse drug events in vulnerable patient populations.

This educational video series from the Centers for Disease Control and Prevention teaches the basic ideas behind infection control, how they work to prevent COVID-19 and how using infection control actions can protect health care workers, their co-workers, patients and the community. Learners can earn a certificate of completion for watching episodes and/or earn continuing education credits through Training and Continuing Education Online.

This Clean Hands Count campaign fact sheet from the Centers for Disease Control and Prevention (CDC) aims to improve health care provider adherence to CDC hand hygiene recommendations.

This fact sheet from the Centers for Disease Control and Prevention list symptoms and responses for several common heat-related illnesses, such as heat stroke and heat exhaustion.

Complete this Data Collection Plan prior to collecting data for a project or monthly measure review in order to identify the data required for the task, identify a goal for each measure, define the source of data, and identify the person(s) responsible for the data collection.

In this podcast from the Institute for Healthcare Improvement, Sue Sheridan of Patients for Patient Safety US describes how she strives for transparency and champions the patient role in developing solutions.

Watch this HQIC Community of Practice Call recorded discussion on how successful and sustainable patient safety improvement rests heavily on an organizational culture of attitudes, actions, teamwork and technology centered on reducing the risk of patient harm.

This series of nearly 20 different infection prevention reference cards from the Health Quality Innovation Network can be downloaded and shared with frontline health care staff. Topics include enhanced barrier precautions, personal protective equipment, cleaning and disinfection, and transmission-based precautions.

This document, provided by the Centers for Disease Control and Prevention (CDC), provides guidance on practical strategies to implement antibiotic stewardship programs in small and critical access hospitals.

This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), provides evidence-based best practices and resources to create quality improvement action plans for catheter-associated urinary tract infection (CAUTI) prevention.

This fact sheet, provided by the Centers for Disease Control and Prevention (CDC), includes frequently asked questions about Methicillin-resistant Staphylococcus aureus (MRSA) for health care professionals as well as patients and families.

This tool, designed by infection preventionists (IPs), provides a comprehensive overview of key areas that all IPs should be familiar with upon entering the field. This list can be used to start an orientation program or serve as a gap analysis for an existing program.

This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), is used to assess the difference between catheter-associated urinary tract infection (CAUTI) prevention actual practice and expected performance. It is important to assess practice through observation and audit rather than relying on if a policy is in place, as practice can vary from policy.

This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), is used to assess the difference between central line associated blood stream infection (CLABSI) prevention actual practice and expected performance. It is important to assess practice through observation and audit rather than relying on if a policy is in place, as practice can vary from policy.

This document, provided by the Centers for Disease Control and Prevention (CDC), provides information on the basic principles and interventions recommended for the prevention of Clostridioides difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations and health care facilities.

This document, provided by the Centers for Disease Control and Prevention (CDC), updates the 2014 Core Elements for Hospital Antibiotic Stewardship Programs and incorporates new evidence and lessons learned from experience with the Core Elements.

This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), helps hospitals provide safer patient care by completing an assessment to identify process improvement opportunities. Hospitals can use the results to develop specific strategies to address gaps and identify resource needs.

This observation tool, provided by the Centers for Disease Control and Prevention (CDC), can be used to observe patients with central lines in place.

The document, provided by The Society for Healthcare Epidemiology of America (SHEA), highlights practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their infection prevention efforts.

According to the Centers for Disease Control and Prevention, health care providers on average clean their hands less than half of the times they should. Limestone Medical Center in Groesbeck, Texas, sought to improve its employee hand hygiene compliance rate, and did, by 96.01 percent.

Preventable harm in health care remains a major concern in the United States, despite substantial effort to improve over the past 20 years. This report from the Institute for Healthcare Improvement provides clear direction for health care leaders, delivery organizations, and associations to make significant advances toward increased safety and reduced harm across the continuum of care.

Research by the Institute for Healthcare Improvement Innovation Team has identified some of the keys to successfully organizing quality departments. By bringing the right people together, building connections across different functions, and distinguishing among different types of quality activities, health care systems can build strong and balanced teams.

View presentations from the 2022 annual National Healthcare Safety Network (NHSN) live training on how to identify, report, and analyze VAE, PedVAE, CAUTI, CLABSI, Secondary Bloodstream Infection (BSI) and Site-Specific Infections, SSI, MRSA Bacteremia and C. difficile LabID events, as well as presentations on validation of healthcare-associated infection data, and reporting and analysis of antibiotic use and resistance data.

Hospitals can use this guide to the effective and consistent monitoring and reporting of hand hygiene compliance for the purposes of improving patient safety.

This tool allows health care providers to document and monitor hand hygiene before and after patient contact and after removal of gloves.

The new StAT (Standards, Approaches and Tactics for Infection Control & Prevention) Learning Series includes a variety of interactive, self-paced learning modules on infection prevention and control in the hospital setting. The series of 15-minute learning modules is produced by the Centers for Medicare & Medicaid Services (CMS) and is tailored to teams leading hospital infection prevention programs and care teams.

Livanta was recently awarded a national contract for Short Stay and Higher Weighted Diagnosis-Related Group (HWDRG) reviews. They will perform these reviews for all 50 states, five U.S. territories, and Washington, DC. Please note that this national contract does not change your state Beneficiary and Family Centered Care Quality Improvement Organization for quality of care reviews and appeals.

Hospitals can use this Tracer Tool to survey and evaluate their processes for reducing ventilator-associate events, with the goal of providing safe, high-quality patient care.

Hospitals can use this Tracer Tool companion document to track quality improvement progress.

Hospitals can use this worksheet to track organizational improvement changes through the Plan, Do, Study, Act cycle.

Hospitals can use this tracer tool to survey and evaluate their processes for surgical site infections (SSI), with the goal of providing safe, high-quality patient care.

Hospitals can use this tracer tool to survey and evaluate their processes for central line-associated bloodstream infections (CLABSI).

Hospitals can use this Tracer Tool to survey and evaluate their processes for catheter-associated urinary tract infections, with the goal of providing safe, high-quality patient care.

Hospitals can use this Tracer Tool to survey and evaluate their processes for reducing patient readmissions, with the goal of providing safe, high-quality patient care.

Hospitals can use this Tracer Tool to survey and evaluate their processes for adverse drug events regarding hypoglycemic agents, with the goal of providing safe, high-quality patient care.

In an effort to get evidenced-based treatment to more Americans with opioid use disorder, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that remove a requirement tied to certain training certification, which some practitioners have cited as a barrier to treating more people.

Hospitals and other health care facilities can download this tool from TMF Health Quality Institute to help them assess their readiness to prevent or react to an adverse drug event.

The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying process improvement opportunities for ventilator-associated events.

The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying improvement opportunities to reduce harm from venous thromboembolism.

A checklist for hospitals to assess current practices to prevent harm from VTE-associated events in your facility.

A checklist for hospitals to review current interventions, or initiate new ones, for VAE reduction in your facility.

QualityNet, from the Centers for Medicare & Medicaid Services (CMS), provides health care quality improvement news, resources, and data reporting tools and applications for providers and others.

This event will provide information for successful submission of CY 2020 electronic clinical quality measure (eCQM) data to the Hospital Inpatient Quality Reporting (IQR) Program and Promoting Interoperability Program.

The Q3 2020 Hospital IQR Program Checklist, available on the Quality Reporting Center website, will assist you in meeting your Q3 2020 Hospital IQR Program requirements.

Improving safety culture in any health care setting involves engaging all team members. This webinar helps established team leaders from the bedside to the board room and across the care continuum discover how to use evidence-based teamwork tools to engage patients and family member as safety champions.

The Agency for Healthcare Research and Quality (AHRQ) shares 10 patient safety tips hospital staff can implement to prevent medical errors and adverse events.

Make sure your patients are up-to-date with pneumococcal vaccination with this CDC guidance on pneumococcal vaccine timing for adults.

Watch this brief video from the Leapfrog Hospital Group that highlights the two most common harms patients experience in a hospital setting and how to prevent them.

The National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB), 2020-2025, presents actions that the United States Government will take in the next five years to improve the health and wellbeing of all Americans by changing the course of antibiotic resistance.