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Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Daley J. Colorado Public Radio. February 17, 2015.
Patient and family stories of harm are increasingly promoted as a strategy to provide insights into medical errors. This radio segment interviews a patient advocate whose daughter died due to medical errors, including failure-to-rescue and a health care–associated infection, and who speaks about that experience to educate clinicians on the importance of patient safety and listening to patients' families.