Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms

References

Adverse Drug Events

Aspden P, Wolcott J, Bootman JL, et al. Preventing medication errors. Washington, DC: National Academies Press; 2006. http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29-34. http://www.ncbi.nlm.nih.gov/pubmed/7791255

Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998, 280:1311-6. http://www.ncbi.nlm.nih.gov/pubmed/9794308

Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized patients: epidemiology and national estimates from a new approach. Jt Comm J Qual Patient Saf 2010,36(1): 12-20, online supplements AP1-AP9. http://www.ncbi.nlm.nih.gov/pubmed/20112660

Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997 Jan 22-29;277(4):301-6. http://www.ncbi.nlm.nih.gov/pubmed/9002492

Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a community hospital. Qual Saf Health Care 2005;14(3):169-74. http://www.ncbi.nlm.nih.gov/pubmed/15933311

Corrigan JM, Donaldson MS, Kohn LT, et al. To err is human: building a safer healthcare system. Washington, DC: National Academies Press; 1999. http://books.nap.edu/catalog.php?record_id=9728

Elixhauser A, Owens P. Adverse drug events in U.S. hospitals, 2004. HCUP Statistical Brief #29. Rockville, MD: Agency for Healthcare Research and Quality; April 2007. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb29.jsp

Hicks RW, Becker SC, Cousins DD, eds. MEDMARX data report. A report on the relationship of drug names and medication errors in response to the Institute of Medicine’s call for action. Rockville, MD: Center for the Advancement of Patient Safety, US Pharmacopeia; 2008.

Johnson CL, Carlson RA, Tucker CL, et al. Using BCMA software to improve patient safety in Veterans Administration Medical Centers. J Healthc Inf Manag 2003;16:46-51. http://www.ncbi.nlm.nih.gov/pubmed/11813523

Office of the Inspector General. Adverse events in hospitals: national incidence among Medicare beneficiaries. OEI-06-09-00090. Washington, DC: U.S. Department of Health and Human Services; November 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf (3.5 MB).

Pennsylvania Patient Safety Authority 2009 Annual Report. Harrisburg: Pennsylvania PSA; April 28, 2010. http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/Annual_Report_2009.pdf (4.1 MB).

Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010;362;1698-1707. http://www.ncbi.nlm.nih.gov/pubmed/20445181

Catheter-Associated Urinary Tract Infections

Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, et al. Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infect Control Hosp Epidemiol 2007;28:791-8. http://www.ncbi.nlm.nih.gov/pubmed/17564980

Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010 Apr;31(4):319-26. http://www.jstor.org/stable/10.1086/651091

Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Pub Hlth Rep 2007;122:160-6. http://www.ncbi.nlm.nih.gov/pubmed/17357358

Rosenthal VD, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol 2004;25:47-50. http://www.ncbi.nlm.nih.gov/pubmed/14756219

Saint S, Kowalski CP, Forman J, et al. A multicenter qualitative study on preventing hospital-acquired urinary tract infection in U.S. hospitals. Infect Control Hosp Epidemiol 2008;29:333-41. http://www.ncbi.nlm.nih.gov/pubmed/18462146

Stephan F, Sax H, Wachsmuth M, et al. Reduction of urinary tract infection and antibiotic use after surgery: A controlled, prospective, before-after intervention study. Clin Infect Dis 2006;42:1544-51. http://www.ncbi.nlm.nih.gov/pubmed/16652311

U.S. Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections. 2009. http://www.hhs.gov/ash/initiatives/hai/infection.html

Zhan C, Elixhauser A, Richards CL Jr, et al. Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value. Med Care 2009 Mar;47(3):364-9. http://www.ncbi.nlm.nih.gov/pubmed/19194330

Central Line-Associated Bloodstream Infections

CDC Vital Signs—Central line associated blood stream infections—U.S. 2001, 2008, 2009. MMWR 2011 Mar 4;60(08):243-8 (e-release March 1, 2011). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm?s_cid=mm6008a4_w

Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Pub Hlth Rep 2007;122:160-6. http://www.ncbi.nlm.nih.gov/pubmed/17357358

Marschall J, Mermell LA, Classen D, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29 Suppl 1:S22-30. http://www.ncbi.nlm.nih.gov/pubmed/18840085

McCarthy D, Chase D. Advancing patient safety in the U.S. Department of Veterans Affairs. New York, NY: Commonwealth Fund; 2011. Pub 1477. Vol. 9. http://www.commonwealthfund.org/publications/case-studies/2011/mar/advancing-patient-safety

Muto C, Herbert C, Harrison E, et al. Reduction in central line-associated bloodstream infections among patients in intensive care units—Pennsylvania, April 2001–March 2005. MMWR 2005;54(40):1013-6. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a2.htm

O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002 Aug 9;51(RR10):1-26. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease cathether-related bloodstream infections in the ICU. N Engl J Med 2006;355(26):2725-32. http://www.ncbi.nlm.nih.gov/pubmed/17192537

Roselle GA. VA healthcare-associated infections activities/initiatives. Slide presentation to HHS HAI Steering Committee, December 9, 2009 (unpublished), and VA "LinKS" data at: http://www.hospitalcompare.va.gov/aspire/index.asp.

Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Atlanta, GA: Centers for Disease Control and Prevention; March 2009. http://stacks.cdc.gov/view/cdc/11550/

Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults, a randomized controlled trial. JAMA 2009;301(12):1231-41. http://www.ncbi.nlm.nih.gov/pubmed/19318651

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. http://www.hhs.gov/ash/initiatives/hai/infection.html

Injury From Falls

Barrett JA, Bradshaw M, Hutchinson K, et al. Reduction of falls-related injuries using a hospital inpatient falls prevention program. J Am Geriatr Soc 2004;52:1969-70. http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2004.52529_8.x/full

Centers for Medicare & Medicaid Services. Medicare program; proposed changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; proposed changes to disclosure of physician ownership in hospitals and physician self-referral rules; proposed collection of information regarding financial relationships between hospitals and physicians. Fed Reg 2008 Apr 30;73(84):23528-23938. http://www.gpo.gov/fdsys/pkg/FR-2008-04-30/html/08-1135.htm

Currie L. Fall and injury prevention (Chapter 10). In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.

Dacenko-Grawe L, Holm K. Evidence-based practice: a falls prevention program that continues to work. Medsurg Nurs 2008 Aug;17(4):223-7, 235.

Department of Veterans Affairs, National Center for Patient Safety. Unpublished data for 2006-2008. (Indicates more than 40% of all reports of adverse events and close calls were of falls: approximately 170,000 of 390,000 reports.)

Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA 2010;304(17):1912-8. http://www.ncbi.nlm.nih.gov/pubmed/21045097

Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004;19:732-9. http://www.ncbi.nlm.nih.gov/pubmed/15209586

Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76. http://www.ncbi.nlm.nih.gov/pubmed/10053175

Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med 2009;360(23):2390-3. http://www.nejm.org/doi/full/10.1056/NEJMp0900963 (Information on Hospital Elder Life Program (HELP) referred to in this article can be found at www.hospitalelderlifeprogram.org.)

Kandilov A, Dalton K, Coomer N. Analysis report: estimating the incremental costs of hospital-acquired conditions (HACS). (Prepared by RTI International under Contract No. 500-T00007.) Baltimore, MD: Centers for Medicare & Medicaid Services;  2011.

Lancaster AD, Ayers A, Belbot B, et al. Preventing falls and eliminating injury at Ascension Health. Jt Comm J Qual Patient Saf 2007 Jul;33(7):367-75. http://www.ncbi.nlm.nih.gov/pubmed/17711138

Mills PD, Neily J, Luan D, Using aggregate root cause analysis to reduce falls. Jt Comm J Qual Patient Saf 2005;31(1):21-31. http://www.ncbi.nlm.nih.gov/pubmed/15691207

Patient Safety Reporting Initiative Updates—February 2006. 2006 Issue 2. Trenton: New Jersey Department of Health and Senior Services. http://www.state.nj.us/health/ps/documents/feb2006_newsletter.pdf (581 KB).

Stalhandske E, Mills P, Quigley P, et al. VHA’s national falls collaborative and prevention programs. In: Advances in patient safety: new directions and alternative approaches. Vol. 2. Culture and Redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2. http://www.ncbi.nlm.nih.gov/books/NBK43724/

Obstetric Adverse Events

Abuhamad A, Grobman WA. Patient safety and medical liability: current status and an agenda for the future. Obstet Gynecol 2010 Sep;116(3):570-7.

Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. Nationwide Inpatient Sample. http://www.hcup-us.ahrq.gov/nisoverview.jsp

Janakiraman V, Ecker J. Quality in obstetric care: measuring what matters. Obstet Gynecol 2010 Sep;116(3):728-32. http://www.ncbi.nlm.nih.gov/pubmed/20733459

Mann S, Pratt S, Gluck P, et al. Assessing quality in obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf 2006;32:497-505. http://www.ncbi.nlm.nih.gov/pubmed/17987873

Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf 2008;34:201-5. http://www.ncbi.nlm.nih.gov/pubmed/18468357

Mazza F, Kitchens J, Kerr S, et al. Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. http://www.ncbi.nlm.nih.gov/pubmed/17283938

Osborne M, Graham J, Cowley K, et al. Because one is too many: Catholic Health Initiatives’ success in reducing preventable birth injuries. J Healthc Qual 2010;32(4):24-30. http://www.ncbi.nlm.nih.gov/pubmed/20618568

Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive strategy on obstetric adverse events. Am J Obstet Gynecol 2009;200(492):e1-8. http://www.ncbi.nlm.nih.gov/pubmed/19249729

Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of CRM-based training on obstetric outcomes and clinicians’ patient safety attitudes. Jt Comm J Qual Patient Saf 2007 Dec;33(12):720-5.

Simpson KR, Kortz CC, Knox GE. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims. Jt Comm J Qual Patient Saf 2009 Nov;35(11):565-74. http://www.ncbi.nlm.nih.gov/pubmed/19947333

The Joint Commission. Preventing maternal death. Sentinel Event Alert Issue 44; January 26, 2010. http://www.jointcommission.org/assets/1/18/SEA_44.pdf (37.5 KB).

Toward improving the outcome of pregnancy III—enhancing perinatal health through quality, safety, and performance initiatives. White Plains, NY: March of Dimes; December 2010. Financial support provided by American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the Association of Women’s Health Obstetric and Neonatal Nurses. www.marchofdimes.org/materials/toward-improving-the-outcome-of-pregnancy-iii.pdf (648 KB).

Pressure Ulcers

Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Nationwide Inpatient Sample. PSI 3. http://qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx

Centers for Medicare & Medicaid Services. Medicare program: proposed changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; proposed changes to disclosure of physician ownership in hospitals and physician self-referral rules; proposed collection of information regarding financial relationships between hospitals and physicians. Fed Reg  2008 Apr 30;73(84):23528–23938. http://www.gpo.gov/fdsys/pkg/FR-2008-04-30/html/08-1135.htm

Gibbons W, Shanks HT, Kleinhelter P, et al. Eliminating facility-acquired pressure ulcers at Ascension Health . Jt Comm J Qual Patient Saf 2006 Sep;32(9):488-96. http://www.ncbi.nlm.nih.gov/pubmed/17987872

Kandilov A, Dalton K, Coomer N. Analysis report: estimating the incremental costs of hospital-acquired conditions (HACS). (Prepared by RTI International under Contract No. 500-T00007). Baltimore, MD: Centers for Medicare & Medicaid Services; 2011.

Nalezny D, et al. Improvement report on reduction of nosocomial pressure ulcers, University of Minnesota Medical Center, Fairview (Minneapolis, Minnesota). Cambridge, MA: Institute for Healthcare Improvement; 2006.

Preventing pressure ulcers in hospitals: a toolkit for improving quality of care. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0053-EF. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/index.html

Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003 Oct 8;290(14):1868-74. http://www.ncbi.nlm.nih.gov/pubmed/14532315

Surgical Site Infections

Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis. N Engl J Med 2010; 362:18-26. http://www.ncbi.nlm.nih.gov/pubmed/20054046

Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009 Jan 29;360(5):491-9. http://www.ncbi.nlm.nih.gov/pubmed/19144931

Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Pub Hlth Rep 2007;122:160-6. http://www.ncbi.nlm.nih.gov/pubmed/17357358

Stulberg, J, Delaney, C, Neuhauser, et al, Adherence to Surgical Care Improvement Project measures and association with postoperative infections, JAMA 2010 Jun 23/30;303:2479-85. http://www.ncbi.nlm.nih.gov/pubmed?term=JAMA%202010%20Stulberg%2C%20J

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. http://www.hhs.gov/ash/initiatives/hai/infection.html

Venous Thromboembolisms (post-surgery)

AHRQ Health Care Innovations Exchange. Algorithm enhances provision of preventive treatment to at-risk inpatients, reducing incidence of venous thromboembolism. https://innovations.ahrq.gov/profiles/algorithm-enhances-provision-preventive-treatment-risk-inpatients-reducing-incidence-venous

AHRQ. Healthcare Cost and Utilization Project. Nationwide Inpatient Sample. PSI 12. http://qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):338S-400S. http://www.ncbi.nlm.nih.gov/pubmed/15383478. Also see the Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism at: http://www.ncbi.nlm.nih.gov/books/NBK44178/.

Heit JA, O’Fallon WM, Petterson TM, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med 2002;162:1245-8. http://www.ncbi.nlm.nih.gov/pubmed/12038942

Johanson NA, Lachiewicz PF, Lieberman JR, et al. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Am Acad Orthop Surg 2009;17:183-96. http://www.ncbi.nlm.nih.gov/pubmed/19264711

Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):454S-545S. (Erratum in Chest 2008 Oct; 134(4):892.) http://www.ncbi.nlm.nih.gov/pubmed/18574272

Kucher N, Koo S, Quiroz R, et al Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005 Mar 10;352(10):969-77. http://www.ncbi.nlm.nih.gov/pubmed/15758007

Maynard G, Stein J. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Prepared by the Society of Hospital Medicine. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. AHRQ Publication No. 08-0075. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html

Maynard GA, Morris TA, Jenkins IH, et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med 2010 Jan;5(1):10-18. http://www.ncbi.nlm.nih.gov/pubmed/19753640

Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm 2007 Jul-Aug;13(6):475-86. http://www.ncbi.nlm.nih.gov/pubmed/17672809

Tapson VF, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005;165:1458-64. http://www.ncbi.nlm.nih.gov/pubmed/16009860

Ventilator-Associated Pneumonias

Berenholtz S, Pham, J, Thompson D, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. J Infect Control Hosp Epidemiol 2011 Apr;32(4):305-14. http://www.ncbi.nlm.nih.gov/pubmed/21460481

de Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. New Engl J Med 2009;360(1):20-31. http://www.ncbi.nlm.nih.gov/pubmed/19118302

Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122:160-6. http://www.ncbi.nlm.nih.gov/pubmed/17357358

McCarthy D, Chase D, Advancing patient safety in the U.S. Department of Veterans Affairs. New York, NY: Commonwealth Fund; 2011. Pub 1477. Vol. 9. http://www.commonwealthfund.org/publications/case-studies/2011/mar/advancing-patient-safety.

Roselle GA. VA healthcare-associated infections activities/initiatives. Slide presentation to HHS HAI Steering Committee, December 9, 2009 (unpublished), and VA "LinKS" data at: http://www.hospitalcompare.va.gov/aspire/index.asp.

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. http://www.hhs.gov/ash/initiatives/hai/infection.html

All Other HACs

de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. http://www.ncbi.nlm.nih.gov/pubmed/18519629

Gawande A. The checklist manifesto: how to get things right. New York, NY: Metropolitan Books; 2010. p. 31. http://gawande.com/the-checklist-manifesto

Hall M, Hamilton B, Richards K, et al. Does surgical quality improve in the American College of Surgeons national Surgical Quality Improvement Program: an evaluation of participating hospitals. Ann Surg 2009 Sep;250(3):363-76. http://www.ncbi.nlm.nih.gov/pubmed/19644350

Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010 Nov 25;363(22):2124-34. http://www.ncbi.nlm.nih.gov/pubmed/21105794

Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010 Oct 20;304(15):1693-700.  http://www.ncbi.nlm.nih.gov/pubmed/20959579

Office of the Inspector General. Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. Department of Health and Human Services; 2010. Publication No. OEI-06-08-00221. http://oig.hhs.gov/oei/reports/oei-06-08-00221.pdf (1.14 MB).

Office of the Inspector General. Adverse events in hospitals: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services; 2010. Publication No. OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf (3.5 MB).

Total HACs

AHRQ and CMS. Medicare Patient Safety Monitoring System Annual Reports (Qualidigm): Unpublished data for 2005, 2006, and 2009.

de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. http://www.ncbi.nlm.nih.gov/pubmed/18519629

Hunt DR, Verzier N, Abenda S, et al. Fundamentals of Medicare safety surveillance: intent, relevance, and transparency. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from research to implementation. Vol. 2: Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005. http://www.ncbi.nlm.nih.gov/books/NBK20489/

Office of the Inspector General. Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. Department of Health and Human Services; 2010. Publication No. OEI-06-08-00221. http://oig.hhs.gov/oei/reports/oei-06-08-00221.pdf (1.14 MB).

Office of the Inspector General. Adverse events in hospitals: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services; 2010. Publication No. OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf (3.5 MB).

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Page originally created December 2014
Internet Citation: References. Content last reviewed December 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhac2013-ref.html
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