Author: IPRO

2023 National Healthcare Safety Network (NHSN); Patient Safety Component Manual

CDC, National Healthcare Safety Network (NHSN)

The Patient Safety Component includes five modules that focus on events associated with medical devices, surgical procedures, antimicrobial agents used during healthcare, multidrug resistant organisms, and Coronavirus Infectious Disease 2019 (COVID-19).

Diagnostic Safety and Quality

Agency for Healthcare Research and Quality (AHRQ)

Diagnostic errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are the primary reason for medical liability claims.  AHRQ is the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error.

  • Issue Briefs
  • Papers
  • Tools to Improve Diagnostic Safety
  • Blogs
  • Patient and Family Engagement

National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination

Office of Disease Prevention and Health Promotion (ODPHP)

In recognition of health care-associated infections (HAIs) as an important public health and patient safety issue, the U.S. Department of Health and Human Services (HHS) convened the Federal Steering Committee for the Prevention of Health Care-Associated Infections (originally called the HHS Steering Committee, but was changed to reflect the addition of agencies outside of HHS). The Steering Committee’s charge is to coordinate and maximize the efficiency of prevention efforts across the federal government. Members of the Steering Committee include clinicians, scientists, and public health leaders representing:

National Action Plans

Agency for Healthcare Research and Quality (AHRQ)

National Action Plans are developed with expert input to provide a framework for collaboration among Government and non-Government entities toward large goals that have significant impact on the Nation’s health.

  • Road Map to Elimination (HAI Action Plan) provides a road map for preventing HAIs in acute care hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities.
  • National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies and opportunities for advancement and seeks to engage stakeholders in a coordinated, aligned, multisector, and health-literate effort to reduce the ADEs that are most common, clinically significant, preventable, and measurable.
  • National Action Plan on Combating Antibiotic Resistant Bacteria provides a roadmap to guide the Nation in rising to the challenge of antibiotic resistance. It outlines steps for implementing the National Strategy for Combating Antibiotic-Resistant Bacteria and addressing the policy recommendations of the President’s Council of Advisors on Science and Technology.

Antibiotic Resistance & Patient Safety Portal

Centers for Disease Control (CDC)

Interactive web-based application that was created to innovatively display data collected through CDC’s National Healthcare Safety Network (NHSN), the Antibiotic Resistance Laboratory Network (AR Lab Network), and other sources.  It offers enhanced data visualizations on Antibiotic Resistance, Use, and Stewardship datasets as well as Healthcare-Associated Infection (HAI) data.

Unavoidable Pressure Injury during COVID-19 Pandemic: A Position Paper from the National Pressure Injury Advisory Panel

National Pressure Injury Advisory Panel (NPIAP)

The purposes of this National Pressure Injury Advisory Panel (NPIAP) Position Paper are to:

  1. Summarize the current NPIAP position regarding unavoidable pressure injuries.
  2. Examine the effects of the COVID-19 crisis on the scope of what is considered an unavoidable pressure injury.
  3. State the position of the NPIAP regarding determinations of unavoidable pressure injuries during the COVID-19 crisis.
  4. Renew the NPIAP call to collaborate on the development of criteria for the determination of unavoidable pressure injuries in acute care.

Skin Manifestations with COVID-19

National Pressure Injury Advisory Panel (NPAIP)

Many reports are occurring concerning areas of purpuric/purple skin and purple toe lesions in patients diagnosed with COVID-19 (SARS-CoV-2). Wound care providers are being asked if these skin lesions are forms of Deep Tissue Pressure Injury and/or “skin failure”. Early reports of COVID-19 related
skin changes included rashes, acral areas of erythema with vesicles or pustules (pseudo-chilblain), other vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis. The pattern and presentation of skin manifestations with COVID-19 is more than rashes. The purpose of this paper is to guide the wound care clinician in determining if the “purple skin” being seen is a deep tissue pressure injury or a cutaneous manifestation of COVID-19.

Sepsis and Health Equity Fact Sheet

Sepsis Alliance

Highlights many racial, ethnic, and socioeconomic disparities related to sepsis. The fact sheet includes the following sepsis disparities:

  • Black and other nonwhite people have nearly twice the incidence of sepsis as whites
  • Non-Hispanic black children admitted to an emergency room are less likely to be treated for sepsis than non-Hispanic white children
  • Native Hawaiians have almost twice the burden of sepsis mortality compared to whites
  • Black children are 30% more likely than white children to develop sepsis after surgery
  • Children with severe sepsis or septic shock who are black or Hispanic are about 25% more likely to die than non-Hispanic white children
  • Adults below the poverty line have more than three to four times the risk of dying of sepsis compared to adults whose family income is at least five times the poverty line