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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 7
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 1
- Teamwork 1
- Device-related Complications 2
- Identification Errors 3
- Medical Complications 6
- Medication Safety 2
- Surgical Complications
- Transfusion Complications
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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.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
May H. Salt Lake Tribune. August 18, 2008.
This article examines 2007 state health data on never events in the context of a label-related medical error that resulted in a recent death.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Journal Article > Commentary
Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites.
Cook J, D'Amato C, Garrett G, Ruhnau-Gee B, Hyde L, Novak N. J AHIMA. 2009;80:62-64.
The authors explain reporting and coding requirements for various types of sentinel event data and describe how these affect coverage.
Special or Theme Issue
Simmons D, ed. Crit Care Nurs Clin North Am. 2010;22:161-290.
Articles in this special issue discuss safe practices, effective staffing, teamwork, and event analysis to enhance patient safety in the critical care setting.
Journal Article > Study
Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures.
Rice-Townsend S, Hall M, Jenkins KJ, Roberson DW, Rangel SJ. J Pediatr Surg. 2010;45:1126-1136.
This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.