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psnet.ahrq.gov/issue/improved-prophylaxis-and-decreased-rates-preventable-harm-use-mandatory-computerized-clinical
June 21, 2016 - preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous … July 19, 2018
Practices to prevent venous thromboembolism: a brief review. … May 24, 2012
Eliminating central line-associated bloodstream infections: a national patient … July 2, 2019
ASH Clinical Practice Guidelines on Venous Thromboembolism. … January 9, 2019
Practices to prevent venous thromboembolism: a brief review.
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www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp5c.html
January 01, 2013 - Units most frequently reported they had fully implemented inclusion of chlorhexidine in their central … 94.7 percent) followed by use of an independent line cart or kit stocked with essentials for placing a central … Most frequently, units reported they had fully implemented inclusion of chlorhexidine in their central … venous line care and, 4) bathe patients in clinical care areas with chlorhexidine. … venous line care?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Donaldson.pdf
January 01, 2003 - Advances in Patient Safety: Vol. 4
290
Content specific to central venous catheter removal was developed … The role
of understaffing in central venous catheter-associated
bloodstream infections. … Central venous catheters. An overview of
Food and Drug Administration activities. … Complications associated with central
venous catheters. A survey. Chest 1988; 94(6):1221–4.
28. … Venous air
embolism from central venous catheterization: a need
for increased physician awareness.
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - Central venous catheters are placed directly into the central veins, usually the subclavian, internal … Evidence-based practice: improving outcomes for patients with a central venous access device. … National survey of central venous catheter flushing in the intensive care unit. … How to obtain a specimen from a central venous catheter. Nursing. 2000;30:14. … A simulation-based "just in time" and "just in place" central venous catheter education program.
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psnet.ahrq.gov/issue/national-partnership-maternal-safety-consensus-bundle-venous-thromboembolism
November 16, 2022 - Commentary
National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism … National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. … Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm . … National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. … Held Too Long
April 1, 2010
WebM&M Cases
Central
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The nurse's lack of
familiarity with the specific type of central venous catheter (CVC) and improper … Central venous catheters are placed directly into the central veins, usually the subclavian, internal … Evidence-based practice: improving outcomes for patients with a central venous access
device. … National survey of central venous catheter flushing in the intensive care
unit. … How to obtain a specimen from a central venous catheter. Nursing. 2000;30:14. [go to PubMed]
10.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-1-tables-6-10.pdf
June 02, 2025 - meningitis 036.0
HIV 042
Meningitis due to enterovirus 047
Other enterovirus diseases of the central … nervous system 048
Other non-arthropod-borne viral diseases of central nervous system 049
Postvaricella … unspecified site
(includes cavernous malformation)
228.00
Phlebitis/thrombophlebitis of
intracranial venous … Cerebral aneurysm, nonruptured 437.3
Moyamoya disease 437.5
Nonpyogenic thrombosis of intracranial
venous … includes anteriovenous malformation)
Cerebrovascular anomalies 747.81
Other (aneurysm) 747.89
Other venous
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www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
December 01, 2014 - Tract Infections
290,000
8.8
CLABSIs
MPSMS (2013)
Blood Stream Infections Associated With Central … Venous Catheters
9,200
0.28
Falls
MPSMS (2013)
In-Hospital Patient Falls
240,000
7.2 … MPSMS (2013)
Ventilator-Associated Pneumonia
37,000
1.1
VTEs
MPSMS (2013)
Postoperative Venous … Antibiotic-Associated C. difficile
100,000
3.1
MPSMS (2013)
Mechanical Complications Associated With Central … Venous Catheters
110,000
3.3
MPSMS (2013)
Postoperative Cardiac Events for Cardiac and Non-cardiac
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/venous-ulcers-treatment-future_research.pdf
January 01, 2014 - ulcers.1 They are caused by
elevated venous pressure, turbulent venous flow, and inadequate venous … effectiveness of treatments
DVT=deep vein thrombosis; KQ=Key Question; PICC=peripherally inserted central … leg ulcers
Arterial/venous surgery for chronic venous leg ulcers caused by mixed arterial and
venous … effectiveness of treatments
DVT=deep vein thrombosis; KQ=Key Question; PICC=peripherally inserted central … does not permit a conclusion, DVT=deep
vein thrombosis; KQ=Key Question; PICC=peripherally inserted central
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psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
September 15, 2021 - This commentary examines factors that contribute to central venous catheterization mistakes and applies … The authors suggest steps before, during, and after central venous catheter placement to support safe … June 1, 2017
WebM&M Cases
Departure From Central
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www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapc.html
January 01, 2013 - venous catheters effective in a real-world setting? … venous catheters. … venous line bundle: epidemiologic and economic consequences. … Does not pertain to CLABSI specific HAI
Shorr AF,
2003
New choices for central venous catheters … venous catheter-associated bloodstream infection in a medical ICU.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/003-clabsi-prevention-webinar-fg.docx
October 01, 2024 - If a central venous catheter is not well secured, the central line can wiggle back and forth with the … A recent review of over 5,000 patients with central venous catheters in a large U.S. health system compared … venous catheter. … The AHRQ CLABSI and CAUTI Prevention Module on Central Venous Catheter Indications and Alternatives offers … that the rate of CLABSI associated with PICCs is like that of conventional central venous catheters
-
www.ahrq.gov/hai/pfp/hacrate2011-12.html
January 01, 2018 - 370,000
11.30
350,000
10.58
CLABSI
MPSMS
Blood Stream Infections Associated With Central … Venous Catheters
17,000
0.52
17,000
0.51
Falls
MPSMS
In-Hospital Patient Falls
260,000 … Ventilator-Associated Pneumonia
35,000
1.07
34,000
1.02
VTE
MPSMS
Postoperative Venous … difficile
100,000
3.16
110,000
3.30
MPSMS
Mechanical Complications Associated With Central … Venous Catheters
130,000
3.84
120,000
3.74
MPSMS
Postoperative Cardiac Events for Cardiac
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www.ahrq.gov/sites/default/files/publications/files/resphys-champions_2.pdf
September 01, 2015 - Nationally, peripheral venous
catheters (PVCs) are used in up to 90 percent of patients, and central … Although serious events
related to PVC use occur less commonly than do those related to central venous … Central Venous Catheters
CVCs are used in the hospital setting to provide patients with venous access … That is, does
the care require central venous access? … Yes No
Central Venous Catheter (CVC)
Dressing intact? Yes No
Site: dry and no erythema?
-
www.ahrq.gov/sites/default/files/publications/files/resphys-champions.pdf
September 01, 2015 - Nationally, peripheral venous
catheters (PVCs) are used in up to 90 percent of patients, and central … Although serious events
related to PVC use occur less commonly than do those related to central venous … Central Venous Catheters
CVCs are used in the hospital setting to provide patients with venous access … That is, does
the care require central venous access? … Yes No
Central Venous Catheter (CVC)
Dressing intact? Yes No
Site: dry and no erythema?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/resphys-champions.pdf
September 01, 2015 - Nationally, peripheral venous
catheters (PVCs) are used in up to 90 percent of patients, and central … Although serious events
related to PVC use occur less commonly than do those related to central venous … Central Venous Catheters
CVCs are used in the hospital setting to provide patients with venous access … That is, does
the care require central venous access? … Yes No
Central Venous Catheter (CVC)
Dressing intact? Yes No
Site: dry and no erythema?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/playbook_revised.pdf
April 01, 2022 - venous catheter; ICU = intensive care unit; PICC = peripherally inserted central catheter … DEMONSTRATION OF CUSP CONCEPTS applied to this intervention:
Abbreviations: CVC = central venous … appropriateness
• Central Venous Catheter Insertion Bundle
o Avoiding improper placement techniques … • Central Venous Catheter Maintenance
o Maintaining awareness and proper care of catheters in place … Catheter impregnation, coating or bonding for
reducing central venous catheter-related infections in
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psnet.ahrq.gov/issue/just-what-doctor-ordered-missed-ordering-venous-thromboembolism-chemoprophylaxis-associated
September 07, 2022 - Study
Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis … Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated … Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient … February 22, 2019
Eliminating central line-associated bloodstream infections: a national … May 10, 2023
Modes of failure in venous thromboembolism prophylaxis.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
April 01, 2022 - flow for therapy such as hemodialysis
☐ Hemodynamic monitoring in critically ill patient
☐ Providing venous … access for placement of a device, such as a pacemaker
☐ Inadequate peripheral venous access
☐ Other … venous catheter (CVC) hub/port (use facility policy if evidence-based) … Do clinicians know which of their patients have central venous catheters? … Meta-analysis of subclavian insertion and non-tunneled central venous catheter associated infection risk
-
psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - reduced using this technique for central venous catheter insertion.( 9,22 ) Simulation-based mastery … learning (SBML) for central venous catheter insertion improves skills ( 9-11 ), retention of skills … Simulation-based mastery learning reduces complications during central venous catheter insertion in a … Use of simulation-based mastery learning to improve the quality of central venous catheter placement … Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123-1133.