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This cross-sectional study in JAMA Network Open looked at patients in the USA with pneumonia who are admitted to hospitals with higher risk-standardised readmission rates. It aimed to assess whether these patients have higher rates of adverse events. The authors found that patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during hospitalisation. This strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.

Non-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.

When hospital patients do not have their teeth brushed it can lead to them developing pneumonia—poor dental hygiene in hospital is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year. In this blog for Medscape, reporter Brett Kelman looks at the link between dental hygiene and hospital-acquired pneumonia, which kills up to 30% of patients who are infected with it. He highlights a lack of understanding of the impact of failing to brush inpatients' teeth, in spite of a growing body of research evidence that links lack of adequate toothbrushing to pneumonia infection.

This article tells the story of Stuart, who died as a result of medication errors while recovering from surgery at a private hospital in January 2013. Stuart had dystonia, an incurable condition that he managed by taking a careful balance of three medications. Following surgery to remove his larynx, the private neurological centre where he was staying ran out of clonazepam, a medication Stuart needed to control his dystonia. Stuart became very unwell, but instead of seeking advice from a doctor, the nurses treated his symptoms as a UTI. on 26 December he was found unresponsive in bed and rushed to ICU at a local hospital. but died a few weeks later from sever kidney and muscle damage. An inquest into Stuart's death found that the lack of clonazepam had caused an increase in Stuart’s muscle spasms, eventually leading to severe muscle and kidney damage. He then developed bronchopneumonia, which was the final factor in his death.

This is the story of the avoidable death of Glyn Davies, as told by his sister Anne. Glyn had an obstruction of the small bowel caused by adhesions from previous surgery and died from aspiration pneumonia after two weeks in intensive care at The Royal Lancaster Infirmary. Glyn's family felt that the investigation following his death had not been dealt with well, with evidence being withheld from the Coroner. This included information in Glyn's medical notes that indicated he had caught the hard-to-treat bacterial infection Stenotrophomonas Maltophilia, from either the ventilator or tubes whilst in intensive care. The family then took legal action against The University Hospitals of Morecambe Bay NHS Foundation Trust and the case was settled out of court in March 2020.

This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.

This report, published by the Association of Anaesthetists, gives recommendations based on clinical experiences of managing patients throughout Italy. In particular, the authors describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non‐technical aspects of caring for patients diagnosed with coronavirus disease 2019. 

This document designed by the Patient Safety Movement is a dynamic document that gives a summary of therapies given to COVID patients in the US.