Patient Safety, Spring 2019 Final CDP Report.

Book/Report

Patient Safety, Spring 2019 Final CDP Report.

March 25, 2020

Patient Safety Standing Committee. February 6, 2020. Washington DC; National Quality Forum. February 2020.

The development of effective measures to document and track patient safety is challenging. This report contributes to a long-standing initiative to define an evolving set of measures to respond to changes in core areas of focus in the field which include hospital-acquired infections and antibioticuse.

Available at

Related Resources From the Same Author(s)

Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report

October 28, 2020

Safe Practices for Better Healthcare–2009 Update.

March 18, 2009

Compendium of Reports.

May 31, 2006

The Care We Need

July 8, 2020

20 Years After “To Err is Human”, Leapfrog Hospital Safety Grades Prove Transparency Can Save Lives.

November 20, 2019

Advancing Anticoagulation Stewardship: A Playbook.

September 7, 2022

Improving Diagnostic Quality and Safety Final Report.

September 27, 2017

Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations.

December 11, 2019

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

April 27, 2016

Common Formats for Event Reporting.

April 20, 2016

Maternal Morbidity and Mortality.

October 30, 2019

Patient Safety Measures.

December 11, 2013

Antibiotic Stewardship in Acute Care: A Practical Playbook.

July 13, 2016

Safe Practices for Better Healthcare: 2010 Update.

April 21, 2010

The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care.

July 7, 2010

Patient Safety 2015: Final Technical Report.

November 12, 2014

Standardizing a Patient Safety Taxonomy.

February 22, 2006

Safe Practices for Better Healthcare: 2006 Update.

March 6, 2005

Serious Reportable Events

December 15, 2010

John M. Eisenberg Patient Safety and Quality Award.

August 7, 2023

Patient Safety Measures: Complications.

January 30, 2005

National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report.

June 27, 2012

Serious Reportable Events in Healthcare—2011 Update.

May 30, 2007

Preventing Medication Errors: A $21 Billion Opportunity.

February 16, 2011

Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.

December 23, 2020

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

December 3, 2008

Crisis Standards of Care: Ten Years of Successes and Challenges–Proceedings of a Workshop.

May 13, 2020

Concurrent and Overlapping Surgeries: Additional Measures Warranted.

January 11, 2017

Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.

December 9, 2020

Commentary on Sentinel & Serious Events Reported by District Health Boards - 2006/07.

March 5, 2008

Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients.

February 3, 2016

The Future of Emergency Care in the United States Health System.

June 21, 2006

Diagnostic Safety Toolkit.

May 27, 2020

Complexity and the Adoption of Innovation in Health Care.

March 6, 2005

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

FactFinders.

February 27, 2019

Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy.

September 28, 2005

Patient Safety: Achieving a New Standard for Care.

March 6, 2005

Becoming a High Reliability Organization.

September 2, 2020

Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety.

February 27, 2008

Crossing the Quality Chasm: A New Health System for the 21st Century.

March 27, 2005

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.

March 18, 2020

Quality and Safety in Women's Health Care. Second Edition.

October 20, 2010

Crossing the Global Quality Chasm: Improving Health Care Worldwide.

September 12, 2018

Health IT and Patient Safety: Building Safer Systems for Better Care.

November 16, 2011

Keeping Patients Safe: Transforming the Work Environment of Nurses.

May 11, 2005

Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR.

January 25, 2023

ASH Clinical Practice Guidelines on Venous Thromboembolism.

January 9, 2019

The Joint Commission and National Quality Forum Announce 2023 Eisenberg Award Recipients.

February 21, 2024

Serious Adverse Events Reports.

March 18, 2009

Organizational Evidence-Based and Promising Practices for Improving Clinician Well-Being.

November 11, 2020

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

To Err Is Human: Building a Safer Health System.

March 27, 2005

Communicating After Harm in Healthcare.

September 8, 2010

Patient Safety: Achieving a New Standard of Care.

December 21, 2005

The Safety of Maternity Services in England.

August 25, 2021

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

January 30, 2003

The Role of Human Factors in Home Health Care: Workshop Summary.

November 10, 2010

Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital?

August 18, 2021

Improving Diagnosis in Health Care.

September 23, 2015

Health Care Comes Home: The Human Factors.

August 3, 2011

Diagnostic Strategy for the COVID-19 Pandemic – Bench to Bedside to Blueprint for Policymakers.

April 22, 2020

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Reducing Diagnostic Error: Measurement Considerations.

August 14, 2019

Nursing Care Quality at NQF.

September 20, 2006

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Improving Diagnostic Accuracy Project 2016–2017.

October 19, 2016

Patient Safety Project 2015–2017.

January 27, 2016

Ambulatory Care Patient Safety 2017–2018.

November 22, 2017

Patient Safety Collaboration.

November 27, 2013

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

December 10, 2008

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

COVID-19 exposes potential gaps in PPE training, effectiveness.

April 22, 2020

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Patient's Toolkit for Diagnosis.

October 12, 2018

Health technology, quality and safety in a learning health system.

February 15, 2023

ACOG Committee Opinion #320: partnering with patients to improve safety.

February 15, 2006

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

September 25, 2013

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

May 27, 2020

WebAIRS Anesthesia Incident Reporting System.

January 1, 2009

A Conversation on Transparency and Patient Safety.

April 13, 2016

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

ACOG Committee Opinion #327: "Do not use" abbreviations.

March 1, 2006

Thirty Safe Practices for Better Health Care.

April 15, 2005

Clinical Reasoning Toolkit.

October 2, 2013

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

March 29, 2006

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Simulation in Healthcare.

April 5, 2006

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.

November 30, 2016

Clinician Well-Being Knowledge Hub.

April 4, 2018

NAM Action Collaborative on Clinician Well-Being and Resilience.

February 15, 2017

The U.S. is repeating its deadliest pandemic mistake.

July 22, 2020

Building a Better Delivery System: A New Engineering/Health Care Partnership.

August 10, 2005

Related Resources

Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus.

April 10, 2024

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

April 3, 2024

The Top Five: A Review of Post-Pandemic Patient Safety Priorities.

March 20, 2024

Top 10 Patient Safety Concerns.

March 12, 2024

The impact of rationing nursing care on patient safety: a systematic review.

January 24, 2024

Patient safety in nursing homes from an ecological perspective: an integrated review.

January 17, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

National and State Healthcare-Associated Infections Progress Report.

November 30, 2023

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: a NBSIs frontline ownership intervention.

November 15, 2023

Voices from frontline nurses on care quality and patient safety during COVID-19: an application of the Donabedian Model.

November 1, 2023

Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic.

August 16, 2023

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

August 9, 2023

Patient Safety Authority Annual Reports.

May 1, 2023

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

April 19, 2023

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

January 25, 2023

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.

December 7, 2022

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report.

November 9, 2022

What is needed to sustain improvements in hospital practices post-COVID-19? A qualitative study of interprofessional dissonance in hospital infection prevention and control.

May 4, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Internet of things in healthcare for patient safety: an empirical study.

March 16, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

February 24, 2022

Care quality, patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for investment in nursing.

January 19, 2022

Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.

July 28, 2021

Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention: a systematic review.

July 14, 2021

Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0

January 29, 2021

Home health staff perspectives on infection prevention and control: implications for Coronavirus Disease 2019.

December 23, 2020

Hospital medication errors: a cross sectional study.

December 23, 2020

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

Missed or Rationed Nursing Care.

December 9, 2020

Nurses' perceived causes of medication administration errors: a qualitative systematic review.

November 25, 2020

See More About The Topic

Hospitals

Quality and Safety Professionals

Hospital Medicine

Nurse Care

Nosocomial Infections