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Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
Washington DC: National Quality Forum; 2010.
The landmark Institute of Medicine (IOM) report, To Err Is Human, called for states to publicly report never events—medical errors that resulted in death or severe disability. This National Quality Forum publication evaluates the current status of state reporting systems 10 years after the IOM report, and summarizes the strengths and limitations of current public reporting initiatives. To date, 28 states maintain some type of reporting system, primarily tracking never events and health care–associated infections. However, states vary significantly in their implementation of these systems, requirements for reporting errors, and regulations regarding analysis and follow-up of errors, limiting the effect of reporting systems on improving patient safety. An AHRQ WebM&M perspective discusses the challenges and opportunities faced by current state reporting systems.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.