U.S. Department of Health & Human Services
Indwelling Tubes and Catheters
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Indwelling Tubes and Catheters
North America (102)
Clinical Guideline (1)
Journal Article (83)
Newspaper/Magazine Article (12)
Press Release/Announcement (3)
Special or Theme Issue (2)
Web Resource (3)
Epidemiology of Errors and Adverse Events (46)
Active Errors (25)
Latent Errors (5)
Approach to Improving Safety
Quality Improvement Strategies (57)
Legal and Policy Approaches (11)
Error Reporting and Analysis (32)
Communication Improvement (7)
Human Factors Engineering (30)
Specialization of Care (3)
Logistical Approaches (3)
Culture of Safety (17)
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Education and Training (22)
Allied Health Services (3)
Health Care Providers (82)
Health Care Executives and Administrators (100)
Non-Health Care Professionals (29)
Setting of Care
Ambulatory Care (2)
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On the CUSP: Stop HAI.
Health Research & Educational Trust, MHA Keystone Center.
Tubing Misconnections Self Assessment for Healthcare Facilities.
Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Fakih MG, George C, Edson BS, Goeschel CA, Saint S. Infect Control Hosp Epidemiol. 2013;34:1048-1054.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
A multidisciplinary approach to reduce central line–associated bloodstream infections.
McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.
Rounding to influence.
Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.
How a simple checklist can dramatically reduce medical errors.
Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.
Five Years of Quality: Working Together to Improve Care.
Tallahassee, FL: Florida Hospital Association; August 2013.
Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.
Murphy DJ, Needham DM, Goeschel C, Fan E, Cosgrove SE, Pronovost PJ. Am J Med Qual. 2010;25:255-260.
Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.
Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
Maintaining and sustaining the
On the CUSP: Stop BSI
model in Hawaii.
Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.
National Healthcare Quality Reports.
Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0002.
Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.
Pakyz AL, Edmond MB. Infect Control Hosp Epidemiol. 2013;34:780-784.
Eliminating CLABSI: A National Patient Safety Imperative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.
Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Ann Intern Med. 2012;157:305-312.
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