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CONTEXT Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact. OBJECTIVE To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization. DESIGN, SETTING, AND PATIENTS The Agency for Healthcare Research and Quality (AHRQ) Patient Safety(More)
OBJECTIVE Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective catheter-care practices to reduce pediatric CA-BSIs. STUDY DESIGN AND(More)
BACKGROUND Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. OBJECTIVE To synthesise peer reviewed knowledge on children's medication errors and on(More)
The technology of intravenous catheter access ports has evolved from open ports covered by removable caps to more-sophisticated, closed versions containing mechanical valves. We report a significant increase in catheter-related bloodstream infections after the introduction of a new needle-free positive-pressure mechanical valve intravenous access port at(More)
Use of patient safety reporting systems (PSRS) to identify and mitigate risks to patients who are harmed by medical care has been a national priority for nearly a decade. Yet, most reporting systems are still new and focus on reporting events. To improve the value of PSRS, we must use the data to identify safety hazards, prioritize where to focus resources,(More)
remarkable variations in processes and outcomes , the interest in quality measurement has increased exponentially. Manifestations of this interest include widespread promulgation of quality measures, an increase in public reporting of these measures, and early experiments in paying for quality. 1,2 Now that quality of care is being measured rather than(More)
OBJECTIVE To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population. METHODS We performed a prospective, interrupted time series study(More)
OBJECTIVES Central lines (CLs) are essential for the delivery of modern cancer care to children. Nonetheless, CLs are subject to potentially life-threatening complications, including central line-associated bloodstream infections (CLABSIs). The objective of this study was to assess the feasibility of a multicenter effort to standardize CL care and CLABSI(More)
OBJECTIVE Pediatric oncology patients are frequently managed with central lines as outpatients, and these lines confer significant morbidity in this immune-compromised population. We aimed to investigate whether a multidisciplinary, central line maintenance care bundle reduces central line-associated bloodstream infections (CLABSIs) and bacteremias in(More)
During a planned, rapid deployment of a modified commercial CPOE product to units at an academic pediatric center, problems from users and staff were collected and entered in text format on a commercially available online problem tracking system. Content analysis of 278 collected text reports collected over 3 weeks after the 24-hour rollout period revealed(More)
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