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Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Study
Li P, Schneider JE, Ward MM. Health Serv Res. 2007;42:2089-2108.
Journal Article > Study
Bazzoli GJ, Chen HF, Zhao M, Lindrooth RC. Health Econ. 2008;17:977-995.
This AHRQ-funded study conducted a detailed economic analysis of acute care hospitals in 11 states and their reported quality and safety of care measures. While unlike a prior study of Florida hospitals, this study found no significant relationship between financial performance and quality of care, the authors highlight a number of important policy implications. They advocate for continued efforts to monitor the quality and safety of care delivered, particularly in hospitals with poor financial performance that are likely to opt out of voluntary reporting to avoid the costs associated with data collection. They also express concern about the impact of pay-for-performance programs that may further limit hospitals with poor financial status from making necessary improvements and investments in care.
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2008. ISBN: 9780833044808
This report analyzes AHRQ's patient safety activities, synthesizes results of the full RAND evaluation, and discusses the knowledge generated by funded research projects as well as how these have contributed to improvement.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Tools/Toolkit > Fact Sheet/FAQs
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; January 07, 2011.
This fact sheet highlights key points of a government effort to link performance on quality with select AHRQ patient safety indicators to raise Medicare reimbursement. The opportunity for submitting comments has passed.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.