1. Agency for Healthcare Research and Quality. Working for Quality: National Quality Strategy (NQS) Reports and Annual Updates. 2011-2016. Available at: http://www.ahrq.gov/workingforquality/reports.htm
2. Agency for Healthcare Research and Quality. Working for Quality: About the National Quality Strategy (NQS). Available at: http://www.ahrq.gov/workingforquality/about.htm
3. Office of Disease Prevention and Health Promotion. National Action Plan to prevent health care-associated infections: Road map to elimination. Available at: https://health.gov/hcq/prevent-hai-action-plan.asp
4. Office of Disease Prevention and Health Promotion. National Action Plan for ADE prevention. Available at https://health.gov/hcq/ade-action-plan.asp
5. Centers for Medicare & Medicaid Services. Partnership for Patients. Available at: https://innovation.cms.gov/initiatives/Partnership-for-Patients/
6. Agency for Healthcare Research and Quality. Comprehensive Unit-based Safety Program (CUSP) Toolkit. Available at https://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html
7. Agency for Healthcare Research and Quality. AHRQ National Scorecard on Rates of Hospital-Acquired Conditions, 2010 to 2015. Available at https://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html
8. Agency for Healthcare Research and Quality. AHRQ Quality and Safety Review System. Available at https://www.ahrq.gov/professionals/quality-patient-safety/qsrs/index.html
9. Centers for Medicare & Medicaid Services (CMS). Hospital-Acquired Condition Reduction Program. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html
10. Centers for Medicare & Medicaid Services. Partnership for Patients: About the Partnership. Available at https://partnershipforpatients.cms.gov/about-the-partnership/what-is-the-partnership-about/lpwhat-the-partnership-is-about.html
12. Institute of Medicine (1999). To err is human: building a safer health system. Available at : http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
13. Institute of Medicine (2001). Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press. Available at: https://www.ncbi.nlm.nih.gov/books/NBK222274/pdf/Bookshelf_NBK222274.pdf
14. Centers for Medicare & Medicaid Services. About the Partnership: Community Based Care Transitions Program. Available at: https://partnershipforpatients.cms.gov/about-the-partnership/community-based-care-transitions-program/community-basedcaretransitionsprogram.html
15. Centers for Medicare & Medicaid Services. Partnership for Patients Initiative. Available at: https://partnershipforpatients.cms.gov/
16. Agency for Healthcare Research and Quality. 2013 annual hospital-acquired condition rate and estimates of cost savings and deaths averted from 2010 to 2013. Available at: https://www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
17. Centers for Medicare & Medicaid Services. Hospital-acquired conditions (present on admission indicator). Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html
18. Centers for Medicare & Medicaid Services. Fiscal Year (FY) 2016 results for the CMS Hospital-Acquired Conditions (HAC) Reduction Program. 2015. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-10-2.html
19. Classen DC, Munier W, Verzier N, et al. Measuring patient safety: The Medicare Patient Safety Monitoring System (past, present, and future). J Patient Safety. 2016; preview online. Available at: http://journals.lww.com/journalpatientsafety/Abstract/publishahead/Measuring_Patient_Safety___The_Medicare_Patient.99576.aspx
20. Agency for Healthcare Research and Quality. Saving lives and saving money: hospital-acquired conditions update interim data from national efforts to make care safer, 2010-2014. Available at: https://www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
21. Brady, J. New system aims to improve patient safety monitoring. Agency for Healthcare Research and Quality, Oct 2016. Available at: http://www.ahrq.gov/news/blog/ahrqviews/new-system-aims-to-improve-patient-safety-monitoring.html
22. Agency for Healthcare Research and Quality. AHRQ Quality and Safety Review System (QSRS). Available at: https://www.ahrq.gov/professionals/quality-patient-safety/qsrs/index.html
23. Winters BD, Bharmal A, Wilson RF, et al. Validity of the Agency for Health Care Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-Acquired Conditions: A systematic review and meta-analysis. Med Care. 2016 Dec;54(12):1105-11.
26. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 July;6(7): e1000097. DOI:10.1371/journal.pmed.1000097
27. Bureau of Labor Statistics. Producer Price-Index. Industry Data, General medical and surgical hospitals (series PCU622110). Available at: http://data.bls.gov/cgi-bin/dsrv?pc
29. Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions. Cochrane DCollaboration, 2011. Available at: http://handbook.cochrane.org/
34. Hoekstra JW, Pollack CV, Roe MT, et al. Improving the care of patients with non-ST-elevation acute coronary syndromes in the emergency department: the CRUSADE initiative. Acad Emerg Med. 2002 Nov;9(11):1146-55.
35. Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf. 2010 Jan;36(1):12–21.
37. LaPointe NMA, Chen AY, Alexander KP, et al. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patients with non ST-segment elevation acute coronary syndromes. Arch Intern Med. 2007 Jul;167(14):1539-44.
38. Seigerman M, Cavallaro P, Itagaki S, et al. Incidence and outcomes of heparin-induced thrombocytopenia in patients undergoing cardiac surgery in North America: an analysis of the nationwide inpatient sample. J Cardiothorac Vasc Anesth. 2014 Feb;28(1):98-102.
45. Yi SH, Baggs J, Gould CV, et al. Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis. Med Care. 2014 Jun;52(6):469-78.
48. Warren DK, Quadir WW, Hollenbeak CS, et al. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Crit Care Med. 2006 Aug;34(8):2084-9.
51. Bohl AA, Phelan EA, Fishman PA, et al. How are the costs of care for medical falls distributed? The costs of medical falls by component of cost, timing, and injury severity. The Gerontologist. 2012 Oct 1;52(5):664-75.
53. Memtsoudis SG, Dy CJ, Ma Y, et al. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. Journ of Arthroplasty. 2012 Jun 30;27(6):823-8.
58. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
64. Bauer K, Rock K, Nazzal M, et al. Pressure ulcers in the United States' inpatient population from 2008 to 2012: results of a retrospective nationwide study. Ostomy Wound Manage. 2016 Nov;62(11):30-8.
69. Kim SP, Shah ND, Karnes RJ, et al. The implications of hospital acquired adverse events on mortality, length of stay and costs for patients undergoing radical cystectomy for bladder cancer. J Urol. 2012 Jun;187(6):2011-7.
73. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 2003 May;31(5):1312-7.
76. Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, et al. Ventilator-associated pneumonia in extremely preterm neonates in a neonatal intensive care unit: characteristics, risk factors, and outcomes. Pediatrics. 2003 Dec;112(6 Pt 1):1283-9.
77. Gupta S, Boville BM, Blanton R, et al. A multicentered prospective analysis of diagnosis, risk factors, and outcomes associated with pediatric ventilator-associated pneumonia. Pediatr Crit Care Med. 2015 Mar;16(3):e65-73.
80. Hayashi Y, Morisawa K, Klompas M, et al. Toward improved surveillance: The impact of ventilator-associated complications on length of stay and antibiotic use in patients in intensive care units. Clin Infect Dis 2013 Feb;56(4):471-7.
88. Agency for Healthcare Research and Quality. AHRQ National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015. Available at: https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html
89. Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention; 2009.
90. Agency for Healthcare Research and Quality. Toolkit for reducing CAUTI in hospitals. Available at https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/cauti-hospitals/index.html
94. Berenholtz SM, Pharm JC, Thompason DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011 Apr;32(4):305-14.