AHRQ Patient Safety Network

The Collection > Policy Makers

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (17)

•Identification Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (26)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (84)

•Medical Complications (69)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (51)

•Transfusion Complications (2)

•Psychological and Social Complications (12)

Origin/Sponsor

•Africa (2)

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Resource Types

•Journal Article (267)

•Legislation/Regulation (22)

•Meeting/Conference (4)

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•Newspaper/Magazine Article (71)

•Press Release/Announcement (3)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

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Error Types

•Epidemiology of Errors and Adverse Events (74)

•Active Errors (28)

•Latent Errors (34)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (125)

•Legal and Policy Approaches (285)

•Error Reporting and Analysis (225)

•Communication Improvement (59)

•Human Factors Engineering (28)

•Teamwork (20)

•Specialization of Care (9)

•Logistical Approaches (34)

•Culture of Safety (70)

•Technologic Approaches (73)

•Education and Training (73)

Clinical Areas

•Medicine (221)

•Nursing (9)

•Pharmacy (29)

Target Audience
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Policy Makers

Setting of Care

•Hospitals (240)

•Psychiatric Facilities (3)

•Residential Facilities (12)

•Ambulatory Care (41)

•Outpatient Surgery (12)

•Patient Transport (1)

1 - 20 of 507

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NEWSPAPER/MAGAZINE ARTICLE

Minnesota is first state with policy to stop billing after medical errors.

Lerner M. Star Tribune. September 18, 2007;News section:5B.

NEWSPAPER/MAGAZINE ARTICLE

Medicare says it won't cover hospital errors.

Pear R. New York Times. August 19, 2007.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

CMS seeks to add 9 hospital-acquired conditions to no-pay list.

O'Reilly KB. American Medical News. May 12, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Insurers stop paying for care linked to errors.

Fuhrmans V. Wall Street Journal. January 15, 2008:D1.

STUDY

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

COMMENTARY

Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.

Clark PA. J Law Med Ethics. 2004;32:349-357.

BOOK/REPORT

HealthGrades Eighth Annual Patient Safety in American Hospitals Study.

Reed K, May R. Denver, CO: HealthGrades, Inc.; March 2011.

COMMENTARY

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Kavanagh KT. Soc Work Public Health. 2011;26:524-541.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

NEWSPAPER/MAGAZINE ARTICLE

Transparency and public reporting are essential for a safe health care system.

Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.

BOOK/REPORT

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2009.

COMMENTARY

The economics of health care quality and medical errors.

Andel C, Davidow SL, Hollander M, Moreno DA. J Health Care Finance. 2012;39:39-50.

NEWSPAPER/MAGAZINE ARTICLE

The impossible workload for doctors in training.

Chen PW. New York Times. April 18, 2013.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

NEWSPAPER/MAGAZINE ARTICLE

CMS: your mistake, your problem.

Lubell J. Modern Healthc. August 20, 2007;37:10.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

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