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Adverse Drug Events

Aspden P, Wolcott J, Bootman JL, et al. Preventing medication errors. Washington, DC: National Academies Press; 2006. .

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. .

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. .

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. .

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. .

Classen, Jaser, reference: 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. .

Corrigan JM, Donaldson MS, Kohn LT, et al. To err is human: building a safer healthcare system. Washington, DC: National Academies Press; 1999. .

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. .

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. .

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.  (3.5 MB).

Pennsylvania Patient Safety Authority 2009 Annual Report. Harrisburg: Pennsylvania PSA; April 28, 2010.  (4.3 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. .

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. .

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. .

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. .

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. .

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. .

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. .

U.S. Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections. 2009. .

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. .

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). .

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. .

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. .

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. .

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. .

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. .

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. .

Roselle GA. VA healthcare-associated infections activities/initiatives. Slide presentation to HHS HAI Steering Committee, December 9, 2009 (unpublished), and VA “LinKS” data at: .

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. .

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. .

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. .

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. 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. .

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. ������ƵPublication 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. .

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. .

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. .

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

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. .

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. .

Patient Safety Reporting Initiative Updates—February 2006. 2006 Issue 2. Trenton: New Jersey Department of Health and Senior Services.  (595 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. ������ƵPublication No. 08-0034-2. .

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. .

Janakiraman V, Ecker J. Quality in obstetric care: measuring what matters. Obstet Gynecol 2010 Sep;116(3):728-32. .

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. .

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. .

Mazza F, Kitchens J, Kerr S, et al. Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. .

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. .

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. .

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. .

The Joint Commission. Preventing maternal death. Sentinel Event Alert Issue 44; January 26, 2010.  (37.55 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.  (3.2 MB).

Pressure Ulcers

Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Nationwide Inpatient Sample. PSI 3. .

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. .

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. .

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. ������ƵPublication 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. .

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. .

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. .

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. .

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. .

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. .

Venous Thromboembolisms (post-surgery)

������ƵHealth Care Innovations Exchange. Algorithm enhances provision of preventive treatment to at-risk inpatients, reducing incidence of venous thromboembolism. .

AHRQ. Healthcare Cost and Utilization Project. Nationwide Inpatient Sample. PSI 12. .

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. Also see the Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism at: .

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. .

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. .

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.) .

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. .

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. ������ƵPublication 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. .

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. .

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. .

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. .

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. .

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. .

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. .

Roselle GA. VA healthcare-associated infections activities/initiatives. Slide presentation to HHS HAI Steering Committee, December 9, 2009 (unpublished), and VA “LinKS” data at: .

U.S. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections. 2009. .

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. .

Gawande A. The checklist manifesto: how to get things right. New York, NY: Metropolitan Books; 2010. p. 31..

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. .

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. .

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. .

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.  (1.135 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.  (3.5 MB).

Total HACs

������Ƶand 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. .

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. .

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.  (1.135 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.  (3.5 MB).