Hospital-Onset Infections: A Patient Safety Issue

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Abstract
Hospital-onset infections, particularly those involving the urinary tract, lung, and bloodstream, are common and costly and cause substantial morbidity. This article analyzes the case of a 78-year-old man with lung cancer who died after developing hospital-onset pneumonia and urinary catheter–related infection during hospitalization for elective removal of a cerebellar metastasis. The field of infection control could benefit by adopting several approaches advocated by patient safety adherents, such as root-cause analysis. For example, hospital-onset infections that are implicated as attributable causes of death should perhaps be reviewed by local infection control teams regardless of the institution's overall infection rates. The patient safety movement can also learn from the traditions of infection control and hospital epidemiology. Specifically, applying infection control–based practices to safety problems may enhance safety. Such practices include establishing clear definitions of adverse events, standardizing methods for detecting and reporting events, creating appropriate rate adjustments for case-mix differences, instituting evidence-based intervention programs, and relying on skilled professionals to promote ongoing improvements in care. * This paper was prepared by Julie Louise Gerberding, MD, MPH, for the Quality Grand Rounds series. Sanjay Saint, MD, MPH, and Kaveh Shojania, MD, prepared the case for presentation.