-
1
-
-
58849122821
-
Centers for Medicare and Medicaid Services' "never events": An analysis and recommendations to hospitals
-
Mattie AS, Webster BL. Centers for Medicare and Medicaid Services' "never events": an analysis and recommendations to hospitals. Health Care Manag (Frederick) 2008;27(4):338-349.
-
(2008)
Health Care Manag (Frederick)
, vol.27
, Issue.4
, pp. 338-349
-
-
Mattie, A.S.1
Webster, B.L.2
-
2
-
-
77949471972
-
Serious reportable adverse events in health care
-
Henriksen K, et al., editors: Programs, Tools, and Products. Rockville, MD: Agency for Healthcare Research and Quality, Accessed Apr 22, 2015
-
Kizer KW, Stegun MB. Serious reportable adverse events in health care. In Henriksen K, et al., editors: Advances in Patient Safety: From Research to Implementation, vol. 4: Programs, Tools, and Products. Rockville, MD: Agency for Healthcare Research and Quality, 2005, 339-352. Accessed Apr 22, 2015. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf.
-
(2005)
Advances in Patient Safety: From Research to Implementation
, vol.4
, pp. 339-352
-
-
Kizer, K.W.1
Stegun, M.B.2
-
6
-
-
84864527487
-
-
Washington, DC: NQF, Accessed Apr 22, 2015
-
National Quality Forum. Serious Reportable Events in Healthcare - 2011 Update: A Consensus Report. Washington, DC: NQF, 2011. Accessed Apr 22, 2015. https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573.
-
(2011)
Serious Reportable Events in Healthcare - 2011 Update: A Consensus Report
-
-
-
7
-
-
79960517063
-
-
Updated: Dec Accessed Apr 22, 2014
-
Agency for Health Care Quality and Research. Patient Safety Primer: Never Events. 2012 (Updated: Dec 2014.) Accessed Apr 22, 2014. http://psnet.ahrq.gov/primer.aspx?primerID=3.
-
(2012)
Patient Safety Primer: Never Events
-
-
-
8
-
-
78650029400
-
Comparing gains and losses
-
McGraw AP, et al. Comparing gains and losses. Psychol Sci. 2010;21(10):1438-1445.
-
(2010)
Psychol Sci.
, vol.21
, Issue.10
, pp. 1438-1445
-
-
McGraw, A.P.1
-
9
-
-
66649092621
-
Ending extra payment for "never events" - Stronger incentives for patients' safety
-
Jun 4
-
Milstein A. Ending extra payment for "never events" - Stronger incentives for patients' safety. N Engl J Med. 2009 Jun 4;360(23):2388-2390.
-
(2009)
N Engl J Med.
, vol.360
, Issue.23
, pp. 2388-2390
-
-
Milstein, A.1
-
10
-
-
84970977742
-
Clarifying "never events" and introducing "always events."
-
Dec 31
-
Lembitz A, Clarke TJ. Clarifying "never events" and introducing "always events." Patient Saf Surg. 2009 Dec 31;3:26.
-
(2009)
Patient Saf Surg.
, vol.3
, pp. 26
-
-
Lembitz, A.1
Clarke, T.J.2
-
11
-
-
85185367269
-
-
Updated: Apr 1, Accessed Apr 22, 2015
-
The Leapfrog Group. Fact Sheet: Never Events. (Updated: Apr 1, 2014.) Accessed Apr 22, 2015. https://leapfroghospitalsurvey.org/web/wp-content/uploads/neverevents.pdf.
-
(2014)
Fact Sheet: Never Events
-
-
-
12
-
-
70149110684
-
Never events": Not every hospital-acquired infection is preventable
-
Sep 1
-
Brown J, Doloresco Iii F, Mylotte JM. "Never events": Not every hospital-acquired infection is preventable. Clin Infect Dis. 2009 Sep 1;49(5):743-746.
-
(2009)
Clin Infect Dis.
, vol.49
, Issue.5
, pp. 743-746
-
-
Brown, J.1
Doloresco, F.2
Mylotte, J.M.3
-
13
-
-
84908164996
-
-
Update. Dec 12, 2013. Accessed Apr 22, 2015
-
NHS England, Patient Safety Domain Team. The Never Events List; 2013/14 Update. Dec 12, 2013. Accessed Apr 22, 2015. http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf.
-
(2013)
The Never Events List
-
-
-
14
-
-
78651254445
-
-
OEI-06-09-00090. Washington, DC: US Department of Health & Human Services, Office of Inspector General, Accessed Apr 22, 2015
-
Golladay KK, et al. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090. Washington, DC: US Department of Health & Human Services, Office of Inspector General, 2010. Accessed Apr 22, 2015. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
-
(2010)
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
-
-
Golladay, K.K.1
-
15
-
-
85185357771
-
-
Accessed Apr 22, 2015
-
The Joint Commission. Patient Safety Systems (PS). 2015. Accessed Apr 22, 2015. http://www.jointcommission.org/assets/1/6/PSC-for-Web.pdf.
-
(2015)
Patient Safety Systems (PS)
-
-
-
16
-
-
84975820806
-
-
Accessed Apr 22, 2015
-
The Joint Commission. Sentinel Events (SE). 2015. Accessed Apr 22, 2015. http://www.jointcommission.org/assets/1/6/CAMH-24-SE-all-CURRENT.pdf.
-
(2015)
Sentinel Events (SE)
-
-
-
20
-
-
77957987000
-
-
Updated: Aug 27, Accessed Apr 22, 2015
-
Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. (Updated: Aug 27, 2014.) Accessed Apr 22, 2015. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired-Conditions.html.
-
(2014)
Hospital-Acquired Conditions
-
-
-
21
-
-
43549086432
-
The wisdom and justice of not paying for "preventable complications."
-
May 14
-
Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications." JAMA. 2008 May 14;299(18):2197-2199.
-
(2008)
JAMA
, vol.299
, Issue.18
, pp. 2197-2199
-
-
Pronovost, P.J.1
Goeschel, C.A.2
Wachter, R.M.3
-
22
-
-
84862897326
-
Limitations of administrative databases
-
Jun 27; author reply 2589-90
-
Haut ER, Pronovost PJ, Schneider EB. Limitations of administrative databases. JAMA, 2012 Jun 27;307(24):2589; author reply 2589-90.
-
(2012)
JAMA
, vol.307
, Issue.24
, pp. 2589
-
-
Haut, E.R.1
Pronovost, P.J.2
Schneider, E.B.3
-
23
-
-
84970987307
-
Medicaid to Stop Paying for Hospital Mistakes
-
Jun 1, Accessed Apr 22, 2015
-
Kaiser Health News. Medicaid to Stop Paying for Hospital Mistakes. Galewitz P. Jun 1, 2011. Accessed Apr 22, 2015. http://www.kaiserhealthnews.org/stories/2011/june/01/medicaid-hospital-medical-error-payment-short-take.aspx.
-
(2011)
Kaiser Health News
-
-
Galewitz, P.1
-
24
-
-
85185366413
-
CMS Releases Hospital Error, Injury Data
-
Apr 8, Accessed Apr 22, 2015
-
MedPage Today. CMS Releases Hospital Error, Injury Data. Walker EP. Apr 8, 2011. Accessed Apr 22, 2015. http://www.medpagetoday.com/PublicHealthPolicy/Medicare/25816.
-
(2011)
MedPage Today
-
-
Walker, E.P.1
-
25
-
-
85185359878
-
-
May 3, Accessed Apr 22, 2015
-
Advisory Board Company. CMS to Remove Never Events Data from Hospital Compare. May 3, 2013. Accessed Apr 22, 2015. http://www.advisory.com/daily-briefing/2013/05/03/cms-to-remove-never-events-datafrom-hospital-compare.
-
(2013)
CMS to Remove Never Events Data from Hospital Compare
-
-
-
26
-
-
85185356574
-
Feds Reverse Course, Will Release Hospital Mistake Data
-
Sep 7, Accessed Apr 22, 2015
-
USA Today, Feds Reverse Course, Will Release Hospital Mistake Data. O'Donnell J. Sep 7, 2014. Accessed Apr 22, 2015. http://www.usatoday.com/story/news/nation/2014/09/07/hhs-change-reporting-hospital-mistakes-foreignobjects/15084175/.
-
(2014)
USA Today
-
-
O'Donnell, J.1
-
27
-
-
79960064801
-
A review of the Office of Inspector General's reports on adverse event identification and reporting
-
Howe CL. A review of the Office of Inspector General's reports on adverse event identification and reporting. J Healthc Risk Manag. 2011;30(4):48-54.
-
(2011)
J Healthc Risk Manag
, vol.30
, Issue.4
, pp. 48-54
-
-
Howe, C.L.1
-
28
-
-
85185358823
-
Individual hospital data on "never events"
-
to be published every quarter. Dec 13
-
Kmietowicz Z. Individual hospital data on "never events" to be published every quarter. BMJ. 2013 Dec 13;347:f7479.
-
(2013)
BMJ
, vol.347
-
-
Kmietowicz, Z.1
-
29
-
-
84875221482
-
Surgical never events in the United States
-
Mehtsun WT, et al. Surgical never events in the United States. Surgery. 2013;153(4):465-472.
-
(2013)
Surgery
, vol.153
, Issue.4
, pp. 465-472
-
-
Mehtsun, W.T.1
-
31
-
-
84974817180
-
-
Dec 12, Accessed Apr 22, 2015
-
NHS England, Patient Safety Domain Team. Never Events Data Summary for 2012/13. Dec 12, 2013. Accessed Apr 22, 2015. http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-data-sum-1213.pdf.
-
(2013)
Never Events Data Summary for 2012/13
-
-
-
32
-
-
65249180158
-
Targeting "never events."
-
Rosenthal K. Targeting "never events." Nurs Manage. 2008;39(12):35-38.
-
(2008)
Nurs Manage
, vol.39
, Issue.12
, pp. 35-38
-
-
Rosenthal, K.1
-
33
-
-
84873187987
-
Avoiding never events: Improving nasogastric intubation practice and standards
-
Law RL, et al. Avoiding never events: Improving nasogastric intubation practice and standards. Clin Radiol. 2013;68(3):239-244.
-
(2013)
Clin Radiol.
, vol.68
, Issue.3
, pp. 239-244
-
-
Law, R.L.1
-
34
-
-
84870424305
-
-
Accessed Apr 22, 2015
-
The Joint Commission. Patient Safety.Accessed Apr 22, 2015. http://www.jointcommission.org/topics/patient-safety.aspx
-
Patient Safety
-
-
-
35
-
-
28844491799
-
Health care provider use of private sector internal error-reporting systems
-
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-312.
-
(2005)
Am J Med Qual.
, vol.20
, Issue.6
, pp. 304-312
-
-
Roumm, A.R.1
Sciamanna, C.N.2
Nash, D.B.3
-
36
-
-
18644383685
-
Five years after To Err Is Human: What have we learned?
-
May 18
-
Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA. 2005May 18;293(19):2384-2390.
-
(2005)
JAMA
, vol.293
, Issue.19
, pp. 2384-2390
-
-
Leape, L.L.1
Berwick, D.M.2
-
37
-
-
79958723416
-
Surveillance bias in outcomes reporting
-
Jun 15
-
Haut ER, Pronovost PJ. Surveillance bias in outcomes reporting. JAMA. 2011 Jun 15;305(23):2462-2463.
-
(2011)
JAMA
, vol.305
, Issue.23
, pp. 2462-2463
-
-
Haut, E.R.1
Pronovost, P.J.2
-
38
-
-
85185364789
-
Measuring adverse events in hospitalized patients: An administrative method for measuring harm
-
Epub Apr 8
-
Martin J, et al. Measuring adverse events in hospitalized patients: An administrative method for measuring harm. J Patient Saf. Epub 2014 Apr 8.
-
(2014)
J Patient Saf
-
-
Martin, J.1
-
39
-
-
84906858395
-
Young and reckless? Greater standardization and transparency of performance is needed for pediatric performance measures
-
Austin JM, Miller MR, Pronovost PJ. Young and reckless? Greater standardization and transparency of performance is needed for pediatric performance measures. Acad Pediatr 2014;14(5 Suppl):S15-16.
-
(2014)
Acad Pediatr
, vol.14
, Issue.5
, pp. S15-S16
-
-
Austin, J.M.1
Miller, M.R.2
Pronovost, P.J.3
-
40
-
-
84974799874
-
Ensuring the integrity and transparency of public reports: How a possible oversight model could benefit healthcare
-
Austin JM, Young GJ, Pronovost PJ. Ensuring the integrity and transparency of public reports: How a possible oversight model could benefit healthcare. American Journal of Accountable Care. 2014;2(4):13-14.
-
(2014)
American Journal of Accountable Care
, vol.2
, Issue.4
, pp. 13-14
-
-
Austin, J.M.1
Young, G.J.2
Pronovost, P.J.3
-
42
-
-
79959270534
-
Explaining Michigan: Developing an ex post theory of a quality improvement program
-
Dixon-Woods M, et al. Explaining Michigan: Developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):167-205.
-
(2011)
Milbank Q
, vol.89
, Issue.2
, pp. 167-205
-
-
Dixon-Woods, M.1
-
43
-
-
84883032902
-
-
Accessed Apr 20, 2015
-
Centers for Medicare & Medicaid Services. Partnership for Patients.Accessed Apr 20, 2015. http://innovation.cms.gov/initiatives/partnership-for-patients/.
-
Partnership for Patients
-
-
-
44
-
-
84907377121
-
Did hospital engagement networks actually improve care?
-
Aug 21
-
Pronovost P, Jha AK. Did hospital engagement networks actually improve care? N Engl J Med. 2014 Aug 21;371(8):691-693.
-
(2014)
N Engl J Med.
, vol.371
, Issue.8
, pp. 691-693
-
-
Pronovost, P.1
Jha, A.K.2
|