U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
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Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
This announcement calls for review and feedback from the field to guide adjustments on a new set of common formats for surveillance of adverse events in hospitals, such as venous thromboembolism and falls.
Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.
Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635.
Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.
Pakyz AL, Edmond MB. Infect Control Hosp Epidemiol. 2013;34:780-784.
2009 Utah Sentinel Events Data Report.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
Hospital Performance Report.
Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Multistate point-prevalence survey of health care–associated infections.
Magill SS, Edwards JR, Bamberg W, et al; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. N Engl J Med. 2014;370:1198-1208.
Getting moving on patient safety—harnessing electronic data for safer care.
Jha AK, Classen DC. N Engl J Med 2011;365:1756-1758.
Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.
Booth CM, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Postgrad Med J. 2011;87:694-699.
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
May H. Salt Lake Tribune. August 18, 2008.
An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act.
General Assembly of Pennsylvania. SB968 (2007).
Sarasota Memorial Hospital reviewed after restrained patient dies.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
Making patient safety the centerpiece of medical liability reform.
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
Health literacy and patient safety events.
Gardner LA. PA-PSRS Patient Saf Advis. June 2016;13:58-65.
Infections associated with reprocessed flexible bronchoscopes.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
Investigating Clinical Incidents in the NHS.
Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886.
Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field.
Chen Q, Shin MH, Chan JA, et al. Am J Med Qual. 2016;31:178-186.
Serious Reportable Events.
Nova Scotia Department of Health and Wellness.
Feds stop public disclosure of many serious hospital errors.
O'Donnell J. USA Today. August 6, 2014.
Maryland hospitals aren't reporting all errors and complications, experts say.
Cohn M. Baltimore Sun. July 26, 2014.
MGH faces suit over drug error that killed woman.
Valencia MJ. Boston Globe. March 10, 2011.
Adverse Events in Hospitals: Public Disclosure of Information About Events.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.
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
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