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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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
Journal Article > Commentary
Conway PH, Clancy C. JAMA. 2009;301:763-765.
This commentary emphasizes five key drivers to improve health care delivery and suggests next steps to accomplish such changes.
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.
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.
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.
Web Resource > Government Resource
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.
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.