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COMMENTARY
Creating high reliability in health care organizations.
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
COMMENTARY
PCA Overdose
Doyle DJ. AHRQ WebM&M [serial online]. July/August 2005.
STUDY
Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.
Maragakis LL, Bradley KL, Song X, et al. Infect Control Hosp Epidemiol. 2006;27:67-70.
NEWSPAPER/MAGAZINE ARTICLE
Leveraging technical and managerial changes to improve safety.
Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.
STUDYclassic
An intervention to decrease catheter-related bloodstream infections in the ICU.
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
STUDY
A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.
Needham DM, Sinopoli DJ, Thompson DA, et al. Crit Care Med. 2005;33:1701-1707.
STUDY
Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.
Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.
STUDY
Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.
Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.
NEWSPAPER/MAGAZINE ARTICLE
Preventing infections: how Portland hospitals compare.
Rojas-Burke J. The Oregonian. May 8, 2010.
NEWSPAPER/MAGAZINE ARTICLE
Top of the list: Researcher fights epidemic of medical errors with checklist.
MacMillan C. Republican-American. March 29, 2009;local:1A. 
NEWSPAPER/MAGAZINE ARTICLE
Deadly infections: hospitals can lower the risk, but many fail to act.
Consumer Reports. March 2010;75:16-21.
STUDY
Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.
Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.
STUDY
Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.
Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.
COMMENTARY
Urinary Retention Dilemma
Joseph AC. AHRQ WebM&M [serial online]. November 2006.
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