AHA (American Hospital Association). 2021. SAFER guides. https://www.aha.org/guidesreports/2014-01-16-safer-guides (accessed March 22, 2021).
AHRQ (Agency for Healthcare Research and Quality). 2021. Listed PSOs. https://www.pso.ahrq.gov/pso/listed (accessed February 20, 2021).
ASRS (Aviation Safety Reporting System). 2021. Program briefing. https://asrs.arc.nasa.gov/overview/summary.html (accessed March 13, 2021).
Babcock, H. M., J. E. Zack, T. Garrison, E. Trovillion, M. Jones, V. J. Fraser, and M. H. Kollef. 2004. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: A comparison of effects. Chest 125(6):2224–2231.
Baehrend, J. 2016. 100,000 Lives Campaign: Ten years later. http://www.ihi.org/communities/blogs/100000-lives-campaign-ten-years-later (accessed February 20, 2021).
Bates, D. W., A. Auerbach, P. Schulam, A. Wright, and S. Saria. 2020. Reporting and implementing interventions involving machine learning and artificial intelligence. Annals of Internal Medicine 172(11 Suppl):S137–S144.
Berwick, D. M., D. R. Calkins, and J. McCannon. 2006. The 100,000 Lives Campaign—Setting a goal and a deadline for improving health care quality. JAMA Network 295(3):324–327.
Bion, J., A. Richardson, P. Hibbert, J. Beer, T. Abrusci, M. McCutcheon, J. Cassidy, J. Eddelston, K. Gunning, G. Bellingan, M. Patten, and D. Harrison. 2012. “Matching Michigan”: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Quality and Safety 22(2):110–123.
Braithwaite, J., D. Marks, and N. Taylor. 2014. Harnessing implementation science to improve care quality and patient safety: A systematic review of targeted literature. International Journal for Quality in Health Care 26(3):321–329.
CDC (Centers for Disease Control and Prevention). 2015. Prevention Epicenters Program. https://www.cdc.gov/hai/epicenters/index.html (accessed February 25, 2021).
CDC. 2020. Vaccine Adverse Event Reporting System (VAERS). https://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html (accessed March 14, 2021).
CDC. 2021. Healthcare Infection Control Practices Advisory Committee (HICPAC). https://www.cdc.gov/hicpac/index.html (accessed March 19, 2021).
Classen, D., R. C. Lloyd, L. Provost, F. Griffin, and R. Resar. 2008. Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool. Journal of Patient Safety 4(3):169–177.
Classen, D., M. Li, S. Miller, and D. Ladner. 2018. An electronic health record–based real-time analytics program for patient safety surveillance and improvement. Health Affairs 37(11):1805–1812.
Damschroder, L. J., D. C. Aron, R. E. Keith, S. R. Kirsh, J. A. Alexander, and J. C. Lowery. 2009. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science 4:50.
Dandala, B., V. Joopudi, C. H. Tsou, J. J. Liang, and P. Suryanarayanan. 2020. Extraction of information related to drug safety surveillance from electronic health record notes: Joint modeling of entities and relations using knowledge-aware neural attentive models. JMIR Medical Informatics 8(7):e18417.
de Feijter, J. M., W. S. de Grave, A. M. Muijtjens, A. J. J. A. Scherpbier, and R. P. Koopmans. 2012. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PLOS ONE 7(2):e31125.
DesRoches, C. M., E. G. Campbell, S. R. Rao, K. Donelan, T. G. Ferris, A. Jha, R. Kaushal, D. E. Levy, S. Rosenbaum, A. E. Shields, and D. Blumenthal. 2008. Electronic health records in ambulatory care—A national survey of physicians. New England Journal of Medicine 359(1):50–60.
Eccles, M. P., and B. S. Mittman. 2006. Welcome to Implementation Science. Implementation Science 1:1.
FAA (Federal Aviation Administration). 2007. FAA Compliance and Enforcement Program. https://fsims.faa.gov/WDocs/Orders/2150_3B.htm (accessed March 25, 2021).
FDA (U.S. Food and Drug Administration). 2014. Drug safety communication: Update on the risk for serious bleeding events with the anticoagulant Pradaxa (dabigatran). http://wayback.archiveit.org/7993/20170112031650/http://www.fda.gov/Drugs/DrugSafety/ucm326580.htm (accessed March 25, 2021).
FDA. 2015. Sentinel Program interim assessment (FY 15). https://www.fda.gov/files/about%20fda/published/Sentinel-Program-Interim-Assessment.pdf (accessed March 25, 2021).
FDA. 2018. FDA drug safety communication: FDA study of Medicare patients finds risks lower for stroke and death but higher for gastrointestinal bleeding with Pradaxa (dabigatran) compared to warfarin. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-study-medicare-patients-finds-risks-lower-stroke-and-death-higher (accessed March 26, 2021).
FDA. 2020. January-March 2020 | Potential signals of serious risks/new safety information identified by the FDA Adverse Event Reporting System (FAERS). https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/january-march-2020-potential-signals-serious-risksnew-safety-information-identified-fda-adverse (accessed March 25, 2021).
Foster, S. 2007. Rotavirus vaccine and intussusception. The Journal of Pediatric Pharmacology and Therapeutics 12(1):4–7.
Gao, X., S. Yan, W. Wu, R. Zhang, Y. Lu, and S. Xiao. 2019. Implications from China patient safety incidents reporting system. Therapeutics and Clinical Risk Management 15:259–267.
Hall, K. K., S. Shoemaker-Hunt, L. Hoffman, S. Richard, E. Gall, E. Schoyer, D. Costar, B. Gale, G. Schiff, K. Miller, T. Earl, N. Katapodis, C. Sheedy, B. Wyant, O. Bacon, A. Hassol, S. Schneiderman, M. Woo, L. LeRoy, E. Fitall, A. Long, A. Holmes, J. Riggs, and A. Lim. 2020. Making healthcare safer III: A critical analysis of existing and emerging patient safety practices. (Prepared by Abt Associates Inc. under Contract No. 233-2015-00013-I.) AHRQ Publication No. 20-0029-EF. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/making-healthcare-safer-III.pdf (accessed March 19, 2021).
Heget, J. R., J. P. Bagian, C. Z. Lee, and J. W. Gosbee. 2002. System innovation: Veterans Health Administration National Center for Patient Safety. The Joint Commission Journal on Quality Improvement 28(12):660–665.
Howell, A., E. M. Burns, G. Bouras, L. J. Donaldson, T. Athanasiou, and A. Darzi. 2015. Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. PLOS ONE 10(12):e0144107.
Huang, S. S., E. Septimus, K. Kleinman, J. Moody, J. Hickok, T. R. Avery, J. Lankiewicz, A. Gombosev, L. Terpstra, F. Hartford, M. K. Hayden, J. A. Jernigan, R. A. Weinstein, V. J. Fraser, K. Haffenreffer, E. Cui, R. E. Kaganov, K. Lolans, J. B. Perlin, and R. Platt for the CDC Prevention Epicenters Program and the AHRQ DECIDE Network and Healthcare-Associated Infections Program. 2013. Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine 368(24):2255–2265.
IHI (Institute for Healthcare Improvement). 2021. National Action Plan to Advance Patient Safety. http://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx (accessed March 22, 2021).
IOM (Institute of Medicine). 2000. To err is human: Building a safer health system. Washington, DC: National Academy Press.
IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
IOM. 2004. Patient safety: Achieving a new standard for care. Washington, DC: The National Academies Press.
IOM. 2012. Health IT and patient safety: Building safer systems for better care. Washington, DC: The National Academies Press.
The Joint Commission. 2021. National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals (accessed March 19, 2021).
Khuri, S. F., J. Daley, W. Henderson, K. Hur, J. Demakis, B. Aust, V. Chong, P. J. Fabri, J. O. Gibbs, F. Grover, K. Hammermeister, G. Irvin, G. McDonald, E. Passaro, L. Phillips, F. Scamman, J. Spencer, and J. Stremple. 1998. The Department of Veterans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Annals of Surgery 228(4):491–507.
Leape, L. L., D. M. Berwick, and D. W. Bates. 2002. What practices will most improve patient safety? Evidence-based medicine meets patient safety. JAMA 288(4):501–507.
Lipshy, K. A., K. Itani, D. Chu, A. Bahadursingh, S. Spector, K. Raman, A. Dardik, E. Tzeng, G. H. Ballantyne, P. R. John, B. Cmolik, J. Maloney, R. Kozol, and W. E. Longo. 2021. Sentinel contributions of U.S. Department of Veterans Affairs surgeons in shaping the face of health care. JAMA Surgery. Published online January 20, 2021.
Meddings, J., M. T. Greene, D. Ratz, J. Ameling, K. E. Fowler, A. J. Rolle, L. Hung, S. Collier, and S. Saint. 2020. Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates. BMJ Quality and Safety 29(5):418–429.
Meyers, D. C., J. A. Durlak, and A. Wandersman. 2012. The quality implementation framework: A synthesis of critical steps in the implementation process. American Journal of Psychology 50(3–4):462–480.
Murff, J. H., F. FitzHenry, M. E. Matheny, N. Gentry, K. L. Kotter, K. Crimin, R. S. Dittus, A. K. Rosen, P. L. Elkin, S. H. Brown, and T. Speroff. 2011. Automated identification of postoperative complications within an electronic medical record using natural language processing. JAMA 306(8):848–855.
Neily, J., G. Ogrinc, P. Mills, R. Wiliams, E. Stalhandske, J. P. Bagian, and W. B. Weeks. 2003. Using aggregate root cause analysis to improve patient safety. The Joint Commission Journal on Quality Improvement 29(8):434–439.
OIG (Office of Inspector General). 2019. Patient safety organizations: Hospital participation, value, and challenges. https://oig.hhs.gov/oei/reports/oei-01-17-00420.asp (accessed March 19, 2021).
Pombo, N., P. Araujo, and J. Viana. 2014. Knowledge discovery in clinical decision support systems for pain management: A systematic review. Artificial Intelligence in Medicine 60(1):1–11.
Pronovost, P., D. Needham, S. Berenholtz, D. Sinopoli, H. Chu, S. Cosgrove, B. Sexton, R. Hyzy, R. Welsh, G. Roth, J. Bander, and J. Kepros. 2006. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine 355(26):2725–2732.
Render, M. L., R. Hasselbeck, R. W. Freyberg, T. P. Hofer, A. E. Sales, and P. L. Almenoff. 2011. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. BMJ Quality and Safety 20(8):725–732.
Rickards, C. A., N. Vyas, K. L. Ryan, K. R. Ward, D. Andre, G. M. Hurst, C. Barrera, and V. A. Convertino. 2014. Are you bleeding? Validation of a machine-learning algorithm for determination of blood volume status: Application to remote triage. Journal of Applied Physiology 116(5):486-494.
Ridelberg, M., K. Roback, P. Nilsen, and S. Carlfjord. 2016. Patient safety work in Sweden: Quantitative and qualitative analysis of annual patient safety reports. BMC Health Services Research 16:98.
Sentinel Initiative. 2021. Sentinel Distributed Database (SDD) statistics summary: 2000–2020. https://www.sentinelinitiative.org/about/key-database-statistics#section-1593025578856 (accessed March 13, 2021).
Shekelle, P. G., R. M. Wachter, P. J. Pronovost, K. Schoelles, K. M. McDonald, S. M. Dy, K. Shojania, J. Reston, Z. Berger, B. Johnsen, J. W. Larkin, S. Lucas, K. Martinez, A. Motala, S. J. Newberry, M. Noble, E. Pfoh, S. R. Ranji, S. Rennke, E. Schmidt, R. Shanman, N. Sullivan, F. Sun, K. Tipton, J. R. Treadwell, A. Tsou, M. E. Vaiana, S. J. Weaver, R. Wilson, and B. D. Winters. 2013. Making healthcare safer II: An updated
critical analysis of the evidence for patient safety practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No.13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyII-full.pdf (accessed March 19, 2021).
Shojania, K. G., B. W. Duncan, K. M. McDonald, R. M. Wachter, and A. J. Markowitz. 2001. Making health care safer: A critical analysis of patient safety practices. (Prepared by University of California, San Francisco (UCSF)–Stanford University Evidence-based Practice Center under Contract No. 290-97-0013.) AHRQ Publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality. https://archive.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf (accessed March 19, 2021).
Shojania, K. G., B. W. Duncan, K. M. McDonald, and R. M. Wachter. 2002. Safe but sound: Patient safety meets evidence-based medicine. JAMA 288(4):508–513.
VHA (Veterans Health Administration). 2021. VHA National Center for Patient Safety. https://www.patientsafety.va.gov (accessed February 25, 2021).
Warren, D. K., J. E. Zack, M. J. Cox, M. M. Cohen, and V. J. Fraser. 2003. An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center. Critical Care Medicine 31(7):1959–1963.
Warren, D. K., J. E. Zack, J. L. Mayfield, A. Chen, D. Prentice, V. J. Fraser, and M. H. Kollef. 2004. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest 126(5):1612–1618.
Warren, D. K., S. E. Cosgrove, D. J. Diekema, G. Zuccotti, M. W. Climo, M. K. Bolon, J. I. Tokars, G. A. Noskin, E. S. Wong, K. A. Sepkowitz, L. A. Herwaldt, T. M. Perl, S. L. Solomon, and V. J. Fraser. 2006. Prevention Epicenter Program. A multicenter intervention to prevent catheter-associated bloodstream infections. Infection Control & Hospital Epidemiology 27(7):662-669.
WHO (World Health Organization). 2020. Patient safety incident reporting and learning systems: Technical report and guidance. Geneva, Switzerland: World Health Organization.
Zack, J. E., T. Garrison, E. Trovillion, D. Clinkscale, C. M. Coopersmith, V. J. Fraser, and M. H. Kollef. 2002. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Critical Care Medicine 30(11):2407–2412.