U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
May H. Salt Lake Tribune. June 26, 2009.
This news story discusses Utah sentinel event statistics and compares them with 2007 data.
Chasing Zero: Winning the War on Healthcare Harm.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
To make hospitals less deadly, a dose of data.
Rosenberg T. New York Times. December 4, 2013.
Program encourages reporting accidents waiting to happen: the Good Catch Awards.
McCook A. Anesthesiology News. Sept 2011;37:9.
Safety of using a computerized rounding and sign-out system to reduce resident duty hours.
Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.
Teamwork on inpatient medical units: assessing attitudes and barriers.
O'Leary KJ, Ritter CD, Wheeler H, Szekendi MK, Brinton TS, Williams MV. Qual Saf Health Care. 2010;19:117-121.
Description of inpatient medication management using cognitive work analysis.
Pingenot AA, Shanteau J, Sengstacke DN. Comput Inform Nurs. 2009;27:379-392.
Why don't doctors wash their hands more?
Chen PW. New York Times. September 17, 2009.
Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
May H. Salt Lake Tribune. August 18, 2008.
Fixing America's hospitals.
Newsweek. October 16, 2006:44-68, 72.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
Surgical 'black box' could reduce errors.
Sathya C. CNN. August 22, 2014
Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.
Judson TJ, Howell MD, Guglielmi C, Canacari E, Sands K. Jt Comm J Qual Patient Saf. 2013;39:468-474.
Lessons from America's safest hospitals.
Howard B. AARP The Magazine. April/May 2013;56:46-50,52,71.
Preventing patient harms through systems of care.
Pronovost PJ, Bo-Linn GW. JAMA. 2012;308:769-770.
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.
How safe is your hospital? Our new ratings find that some are riskier than others.
Consum Rep. 2012 Aug;77:20-28.
Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.
Hundt AS, Adams JA, Schmid JA, et al. Int J Med Inform. 2013;82:25-38.
A relational leadership perspective on unit-level safety climate.
Thompson DN, Hoffman LA, Sereika SM, et al. J Nurs Adm. 2011;41:479-487.
Pressing for better quality across healthcare.
Levey NN. Los Angeles Times. October 4, 2011.
Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.
Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.
Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.
Kavanagh KT. Soc Work Public Health. 2011;26:524-541.
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.
Improving the usability of intravenous medication labels to support safe medication delivery.
Bauer DT, Guerlain S. Int J Ind Ergon. 2011;41:394-399.
Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.
Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364