Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 1
- Education and Training 8
- Error Reporting and Analysis 12
- Human Factors Engineering 8
- Legal and Policy Approaches 12
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 8
- Technologic Approaches 3
- Device-related Complications 5
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 32
- Medication Safety 2
- Surgical Complications 6
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Tools/Toolkit > Fact Sheet/FAQs
Chicago, IL: National Patient Safety Foundation.
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines practical tips to minimize risk.
Grady D. New York Times. April 30, 2005.
The author reports on incidents in an Angolan hospital where doctors and patients were exposed to a deadly virus when hospital staff violated infection control procedures.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Journal Article > Commentary
Zeller JL, Burke AE, Glass RM. JAMA. 2007;298:1826.
This fact sheet defines the methicillin-resistant Staphylococcus aureus (MRSA) bacterium, identifies causes of infection and risk factors, and provides information on treatment and prevention.
Gross T. "Fresh Air." National Public Radio. January 9, 2008.
This interview with Richard Shannon, MD, addresses the safety consequences of hospital-acquired infections and discusses prevention tactics for health care leaders and front-line providers.
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
Berens MJ, Armstrong K. Seattle Times. November 16-18, 2008.
This three-part journalistic investigation highlights efforts in Washington State to track and minimize the spread of methicillin-resistant Staphylococcus aureus (MRSA) and to address organizational resistance to changes needed to mitigate the problem.
Goldhill D. The Atlantic. September 2009.
In the context of his father's death from a hospital-associated infection, the author discusses health system reform and quality of care in the United States.
Chen PW. New York Times. September 17, 2009.
The author uses personal experience to explain how sterile technique is strict in the operating room. The column highlights the Joint Commission effort to improve hand hygiene compliance in the health care system as a whole.
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through his articles in The New Yorker on topics ranging from quality improvement to the costs of health care, and his books, Complications and Better. In his new book, The Checklist Manifesto: How to Get Things Right, Dr. Gawande elegantly describes the history of the checklist as a quality and safety tool, in fields ranging from flying airplanes to building skyscrapers. In health care, he focuses on the Michigan Keystone Project, in which the use of checklists led to a remarkable decrease in the rate of central line–associated bloodstream infections, and on his own work with the World Health Organization's Safe Surgery Saves Lives program, where checklist use was associated with a striking decrease in surgical complications. An AHRQ WebM&M interview with Dr. Gawande discusses professionalism, surgical errors, and patient safety. A Patient Safety Primer on checklists is also featured on AHRQ PSNet.
Consumer Reports. March 2010;75:16-21.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Hamill SD. Pittsburgh Post-Gazette. April 18, 2010:A1.
This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Tampa, FL: Sepsis Alliance; 2010.
Revealing incidents in which diagnostic delay led to sepsis, this video provides information to help consumers recognize the condition.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Edmonton, AB, Canada: Canadian Patient Safety Institute; March 2011.
Explaining the importance of hand hygiene in the health care setting, this publication provides strategies for patients and families to prevent spreading health care–associated infections.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.