Commentary Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. Citation Text: Cook J, D'Amato C, Garrett G, et al. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. J AHIMA. 2009;80(6):62-4; quiz 67-8. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL August 19, 2009 Cook J, D'Amato C, Garrett G, et al. J AHIMA. 2009;80(6):62-4; quiz 67-8. View more articles from the same authors. The authors explain reporting and coding requirements for various types of sentinel event data and describe how these affect coverage. PubMed citation Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Cook J, D'Amato C, Garrett G, et al. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. J AHIMA. 2009;80(6):62-4; quiz 67-8. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices. June 28, 2017 HIM functions in healthcare quality and patient safety. August 10, 2011 Ticket to ride: reducing handoff risk during hospital patient transport. September 10, 2008 Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment. June 22, 2005 Communication disparities between nursing home team members. July 20, 2022 The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors. April 27, 2016 The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study. October 2, 2013 Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. November 12, 2008 Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. February 16, 2022 Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021 Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023 Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. April 12, 2023 Going blank: factors contributing to interruptions to nurses' work and related outcomes. December 1, 2010 Losing the moment: understanding interruptions to nurses' work. May 19, 2010 The impact of adverse events on clinicians: what's in a name? November 22, 2017 Using an advanced practice nursing model for a rapid response team. December 3, 2008 Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. September 10, 2008 Exploring organizational context and structure as predictors of medication errors and patient falls. May 28, 2008 The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial. March 27, 2005 Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic. April 5, 2023 Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023 The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021 Error traps in pediatric patient blood management in the perioperative period. September 6, 2023 Improving safety through speaking up: an ethical and financial imperative. July 24, 2019 Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. December 11, 2013 Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial. December 12, 2012 Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. January 8, 2020 Engineering risk analysis of a hospital oxygen supply system. April 5, 2006 Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. June 28, 2017 Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety. October 1, 2014 Attitudes toward safety and teamwork in a maternity unit with embedded team training. November 3, 2010 Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. January 22, 2014 Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. September 13, 2017 Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. February 11, 2009 The incidence of adverse drug events in two large academic long-term care facilities. April 15, 2005 Unintended consequences of online consultations: a qualitative study in UK primary care. February 2, 2022 Unintended consequences of patient online access to health records: a qualitative study in UK primary care. November 16, 2022 How well do health professionals interpret diagnostic information? A systematic review. August 12, 2015 National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals. June 20, 2018 Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. July 22, 2020 Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps. December 6, 2023 Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies. August 30, 2023 Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics. June 7, 2023 Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up. October 29, 2014 Evolution of a rapid response system from voluntary to mandatory activation. June 9, 2010 Influencing leadership perceptions of patient safety through just culture training. May 5, 2010 Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. December 11, 2013 Impact of a pharmacotherapy alerting system on medication errors. January 23, 2013 Medication discrepancies upon hospital to skilled nursing facility transitions. April 29, 2009 Adverse drug events resulting from patient errors in older adults. March 7, 2007 Are you listening...Are you really listening? September 17, 2008 Dispensing error rate in a highly automated mail-service pharmacy practice. November 23, 2005 Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. August 19, 2020 Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020 Perioperative team-based morbidity and mortality conferences: a systematic review of the literature. October 11, 2023 Knowledge retention after simulated crisis: importance of independent practice and simulated mortality. June 5, 2019 Evaluating the impact of auto-calculation settings on opioid prescribing at an academic medical center. May 8, 2019 The impact of a pharmacist's participation on hospitalists' rounds. March 10, 2010 Improving operating room safety. December 16, 2009 The role of advice in medication administration errors in the pediatric ambulatory setting. September 9, 2009 Effective perioperative communication to enhance patient care. September 14, 2016 Primary care physician communication at hospital discharge reduces medication discrepancies. December 18, 2013 The effects of resident level of training on the rate of pediatric prescription errors in an academic emergency department. February 13, 2013 Developing and implementing a standardized process for Global Trigger Tool application across a large health system. July 10, 2013 A framework for operationalizing risk: a practical approach to patient safety. May 2, 2018 Developing and evaluating an automated all-cause harm trigger system. March 8, 2017 The pharmacist-physician relationship in the detection of ambulatory medication errors. January 31, 2006 The effect of nurse staffing patterns on medical errors and nurse burnout. June 25, 2008 Paying the piper: investing in infrastructure for patient safety. June 4, 2008 Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. April 3, 2005 Reforming the Veterans Health Administration—beyond palliation of symptoms. October 14, 2015 Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study. May 20, 2015 Rapid response team implementation and in-hospital mortality. August 27, 2014 Team training of medical students in the 21st century: would Flexner approve? February 17, 2010 National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia. August 25, 2010 Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors. October 12, 2011 Patient safety events and harms during medical and surgical hospitalizations for persons with serious mental illness. June 1, 2016 Learning from every death. March 5, 2014 Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. March 13, 2013 A relational leadership perspective on unit-level safety climate. November 9, 2011 Peer support in anesthesia: turning war stories into wellness. August 15, 2018 The practice of respect in the ICU. August 1, 2018 Provider perspectives on partnering with parents of hospitalized children to improve safety. June 27, 2018 Parents' perspectives on "keeping their children safe" in the hospital. November 30, 2016 Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness. August 9, 2017 A national study links nurses' physical and mental health to medical errors and perceived worksite wellness. March 21, 2018 Patient safety issues continue to plague American hospitals. August 14, 2019 A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009 Analysis of medical emergency team calls comparing subjective to "objective" call criteria. November 12, 2008 Follow-up tips for a safe, efficient practice. May 31, 2006 Medical errors: should you apologize? May 3, 2006 Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. April 4, 2007 Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. January 31, 2006 Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. April 2, 2008 Driving improvement in patient care: lessons from Toyota. March 6, 2005 New York-Presbyterian Hospital: translating innovation into practice. October 12, 2005 An integrative review: fatigue among nurses in acute care settings. November 5, 2014 Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023 TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. September 11, 2019 Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. April 21, 2021 View More Related Resources The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. April 24, 2024 The Top Five: A Review of Post-Pandemic Patient Safety Priorities. March 20, 2024 A 7-year analysis of attributable costs of healthcare-associated infections in a network of community hospitals in the southeastern United States. January 31, 2024 The impact of rationing nursing care on patient safety: a systematic review. January 24, 2024 Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical record review across nine Swiss hospitals. January 10, 2024 Voices from frontline nurses on care quality and patient safety during COVID-19: an application of the Donabedian Model. November 1, 2023 WebM&M Cases A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 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 Staying safe while getting well. August 16, 2023 Preventing surgical site infections: implementing strategies throughout the perioperative continuum. July 19, 2023 Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. June 14, 2023 Why hospitals still make serious medical errors—and how they are trying to reduce them. March 29, 2023 Sources of nurse-sensitive inpatient safety improvement. December 21, 2022 Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. December 14, 2022 Using community detection techniques to identify themes in COVID-19-related patient safety event reports. December 7, 2022 Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022 Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. October 5, 2022 WebM&M Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. September 14, 2022 Association between hospital acquired harm outcomes and membership in a national patient safety collaborative. August 10, 2022 Mortality due to hospital-acquired infection after cardiac surgery. June 1, 2022 Cost of health care-associated infections in the United States. March 23, 2022 Applying decision science to the prioritization of healthcare-associated infection initiatives. October 27, 2021 Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. September 29, 2021 The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. September 22, 2021 Organizational readiness to change as a leverage point for improving safety: a national nursing home survey. September 8, 2021 Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021 Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. June 16, 2021 Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. April 14, 2021 In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. March 24, 2021 View More See More About The Topic Hospitals Health Care Executives and Administrators Nosocomial Infections Pressure Ulcers Venous Thrombosis and Thromboembolism View More
Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices. June 28, 2017
Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment. June 22, 2005
The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors. April 27, 2016
The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study. October 2, 2013
Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. November 12, 2008
Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. February 16, 2022
Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021
Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023
Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. April 12, 2023
Going blank: factors contributing to interruptions to nurses' work and related outcomes. December 1, 2010
Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. September 10, 2008
Exploring organizational context and structure as predictors of medication errors and patient falls. May 28, 2008
The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial. March 27, 2005
Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic. April 5, 2023
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021
Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. December 11, 2013
Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial. December 12, 2012
Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. January 8, 2020
Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. June 28, 2017
Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety. October 1, 2014
Attitudes toward safety and teamwork in a maternity unit with embedded team training. November 3, 2010
Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. January 22, 2014
Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study. September 13, 2017
Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. February 11, 2009
Unintended consequences of online consultations: a qualitative study in UK primary care. February 2, 2022
Unintended consequences of patient online access to health records: a qualitative study in UK primary care. November 16, 2022
How well do health professionals interpret diagnostic information? A systematic review. August 12, 2015
National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals. June 20, 2018
Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. July 22, 2020
Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps. December 6, 2023
Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies. August 30, 2023
Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics. June 7, 2023
Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up. October 29, 2014
Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. December 11, 2013
Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. August 19, 2020
Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020
Perioperative team-based morbidity and mortality conferences: a systematic review of the literature. October 11, 2023
Knowledge retention after simulated crisis: importance of independent practice and simulated mortality. June 5, 2019
Evaluating the impact of auto-calculation settings on opioid prescribing at an academic medical center. May 8, 2019
The role of advice in medication administration errors in the pediatric ambulatory setting. September 9, 2009
Primary care physician communication at hospital discharge reduces medication discrepancies. December 18, 2013
The effects of resident level of training on the rate of pediatric prescription errors in an academic emergency department. February 13, 2013
Developing and implementing a standardized process for Global Trigger Tool application across a large health system. July 10, 2013
The pharmacist-physician relationship in the detection of ambulatory medication errors. January 31, 2006
Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. April 3, 2005
Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study. May 20, 2015
National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia. August 25, 2010
Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors. October 12, 2011
Patient safety events and harms during medical and surgical hospitalizations for persons with serious mental illness. June 1, 2016
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. March 13, 2013
Provider perspectives on partnering with parents of hospitalized children to improve safety. June 27, 2018
Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness. August 9, 2017
A national study links nurses' physical and mental health to medical errors and perceived worksite wellness. March 21, 2018
A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009
Analysis of medical emergency team calls comparing subjective to "objective" call criteria. November 12, 2008
Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. April 4, 2007
Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. January 31, 2006
Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023
TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. September 11, 2019
Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. April 21, 2021
The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. April 24, 2024
A 7-year analysis of attributable costs of healthcare-associated infections in a network of community hospitals in the southeastern United States. January 31, 2024
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical record review across nine Swiss hospitals. January 10, 2024
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
Preventing surgical site infections: implementing strategies throughout the perioperative continuum. July 19, 2023
Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. June 14, 2023
Why hospitals still make serious medical errors—and how they are trying to reduce them. March 29, 2023
Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. December 14, 2022
Using community detection techniques to identify themes in COVID-19-related patient safety event reports. December 7, 2022
Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022
Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. October 5, 2022
WebM&M Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022
Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. September 14, 2022
Association between hospital acquired harm outcomes and membership in a national patient safety collaborative. August 10, 2022
Applying decision science to the prioritization of healthcare-associated infection initiatives. October 27, 2021
Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. September 29, 2021
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. September 22, 2021
Organizational readiness to change as a leverage point for improving safety: a national nursing home survey. September 8, 2021
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021
Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. June 16, 2021
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. April 14, 2021
In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. March 24, 2021