Studies & Research

Agency for Healthcare Research and Quality Reports

American Hospital Association

AHRQ Issues Healthcare Associated Infections Research Protocol

Article: Study Reveals Medical Errors and Claims are Increasing in Outpatient Settings Compared to Hospitals

CDC Reports on Sepsis Hospitalizations and Cost – This report from the Centers for Disease Control and Prevention reveals sepsis and related hospitalizations more than doubled between 2000 and 2008, costing $14.6 billion in 2008.

Commonwealth Reports On Hospitals Reporting No CLABSIs in ICUs – This new report from the Commonwealth Fund offers lessons from hospitals that have not experienced any central line associated blood stream infections in their ICUs in 2009.

Consumer’s Union Reports

Crossing the Quality Chasm: A New Health System for the 21st Century – an urgent call for change to close the quality gap, recommending redesign of the American health care system

Governmental Accounting office (GAO) Patient Safety Reports

Health Affairs

HCProInc: The Drive to Safety:  HealthLeaders Intelligence Report – Results of this study reveals improving patient safety is a driving force in health care; ongoing challenges are communication and leadership structures to support safety.

Health Grades

Health Research & Educational Trust

HIMSS Safety Reports

Institute of Medicine – Quality and Safety Reports

Institute for Safe Medication Practices – QuarterlyWatch

IOM – To Err is Human: Building A Safer Health System – Landmark report laying out a comprehensive strategy to reduce preventable medical errors

Joint Commission Safety Reports

Kaiser Foundation – Report on Patient Satisfaction by State

Massachusetts Office of Health and Human Services

Minnesota Department of Health

Missouri Commission on Patient Safety

National Quality Forum

New Jersey Annual Reports

New York State Department of Health

Oregon Patient Safety Report Reveals Limited Improvement, Culture Change Needed – The report from the Oregon Patient Safety Commission reports findings from voluntary reports from 56 of the state’s 58 hospitals.

Patient Safety Classics – Resource from the Agency for Healthcare Research and Quality

Pennsylvania Patient Safety Authority Reports

Public Citizen Reports

Safe Practices for Better Healthcare

The Commonwealth Fund – Quality Reports

USP – MedMaRx Reports

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.