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2003 National Healthcare Quality Report

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Chapter 4. Patient Safety


1 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-6.

2 Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324(6):377-84.

3 Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry 1999;36(3):255-64.

4 Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38(3):261-71.

5 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;277(4):301-6.

6 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(1):29-34.

7 Kohn L, Corrigan J, Donaldson M, et al. To err Is human: building a safer health system. Washington, DC: National Academies Press; 2000. Available at: Disclaimer Accessed December 18, 2003.

8 Stein R. Teenage girl in botched organ transplant dies. The Washington Post 2003 Feb 23; Sect. A:01.

9 New York State Department of Health. State health department cites Mt. Sinai Medical Center for deficient care in living liver donor death [Press Release]. 2002 Mar 12.

10 Quality Interagency Coordination Task Force. Doing what counts for patient safety: federal actions to reduce medical errors and their impact. Washington, DC: U.S. Quality Interagency Coordination Task Force; 2000.

11 Layde PM, Cortes LM, Teret SP, et al. Patient safety efforts should focus on medical injuries. JAMA 2002;287(15):1993-7.

12 Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press; 2001.

13 McNutt RA, Abrams R, Arons DC. Patient safety efforts should focus on medical errors. JAMA 2002;287(15):1997-2001.

14 U. S. Department of Health and Human Services. The challenge and potential for assuring quality health care for the 21st century. Washington DC: U. S. Department of Health and Human Services; 2000.

15 President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality first: better health care for all Americans; 1998.

16 Romano PS, Geppert JJ, Davies S, et al. A national profile of patient safety in U.S. hospitals. Health Aff (Millwood) 2003;22(2):154-66.

17 Romano PS, Geppert J, Davies SM, et al. Measures of patient safety based on hospital administrative data — the Patient Safety Indicators. Technical Review Number 5. Rockville, MD: Agency for Healthcare Research and Quality; 2002. AHRQ Publication No. 02-0038. Available at: Accessed July 15, 2010.

18 Lawthers AG, McCarthy EP, Davis RB, et al. Identification of in-hospital complications from claims data. Is it valid? Med Care 2000;38(8):785-95.

19 Bates DW, O'Neil AC, Petersen LA, et al. Evaluation of screening criteria for adverse events in medical patients. Med Care 1995;33(5):452-62.

20 Weingart SN, Iezzoni LI, Davis RB, et al. Use of administrative data to find substandard care: validation of the complications screening program. Med Care 2000;38(8):796-806.

21 McCarthy EP, Iezzoni LI, Davis RB, et al. Does clinical evidence support ICD-9-CM diagnosis coding of complications? Med Care 2000;38(8):868-76.

22 Romano PS, Chan BK, Schembri ME, et al. Can administrative data be used to compare postoperative complication rates across hospitals? Med Care 2002;40(10):856-67.

23 Monitoring hospital-acquired infections to promote patient safety — United States, 1990-1999. MMWR Morb Mortal Wkly Rep 2000;49(8):149-53.

24 National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 to June 2002, issued August 2002. Am J Infect Control 2002;30(8):458-75.

25 Kent P, McDonald M, Harris O, et al. Post-discharge surgical wound infection surveillance in a provincial hospital: follow-up rates, validity of data and review of the literature. ANZ J Surg 2001;71(10):583-9.

26 Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001;286(22):2823-9.

27 Cobbs E, Duthie Jr E, Murphy J, editors. Geriatrics review syllabus: a core curriculum in geriatric medicine. New York, NY: Kendall/Hunt Publishing Company; 1999.

28 Wallace WC, Cinat ME, Nastanski F, et al. New epidemiology for postoperative nosocomial infections. Am Surg 2000;66(9):874-8.

29 Soufir L, Timsit JF, Mahe C, et al. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999;20(6):396-401.

30 Weinstein RA. Nosocomial infection update. Emerg Infect Dis 1998;4(3). Available at:

31 Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348(3):229-35.

32 Jason RS, Chisolm A, Lubetsky HW. Retained surgical sponge simulating a pancreatic mass. J Natl Med Assoc 1979;71(5):501-3.

33 Despars JA, Sassoon CS, Light RW. Significance of iatrogenic pneumothoraces. Chest 1994;105(4):1147-50.

34 Candido LC. Treatment of surgical wound dehiscence. Dermatol Nurs 2002;14(3):177-8, 181.

35 Bradbury M, Cruickshank JP. Blood transfusion: crucial steps in maintaining safe practice. Br J Nurs 2000;9(3):134-8.

36 Stephan F, Boucheseiche S, Hollande J, et al. Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors. Chest 2000;118(5):1263-70.

37 White R, Henderson M. Risk factors for venous thromboembolism after total hip and knee replacement. Curr Opin Pulm Med 2002;8(5):365-71.

38 Jackson MR. Diagnosis and management of venous thrombosis in the surgical patient. Semin Thromb Hemost 1998;24 Suppl 1:67-76.

39 Iezzoni LI, Daley J, Heeren T, et al. Using administrative data to screen hospitals for high complication rates. Inquiry 1994;31(1):40-55.

40 Hoffman GM, Nowakowski R, Troshynski TJ, et al. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics 2002;109(2):236-43.

41 Faccenda KA, Finucane BT. Complications of regional anaesthesia incidence and prevention. Drug Saf 2001;24(6):413-42.

42 Whitfield MD, Kaltenthaler EC, Akehurst RL, et al. How effective are prevention strategies in reducing the prevalence of pressure ulcers? J Wound Care 2000;9(6):261-6.

43 Tepp J, Voitk A. Hip fracture as a complication of hospitalization. Int J Health Care Qual Assur Inc Leadersh Health Serv 1999;12(6-7):x-xiii.

44 Hughes CA, Harley EH, Milmoe G, et al. Birth trauma in the head and neck. Arch Otolaryngol Head Neck Surg 1999;125(2):193-9.

45 Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329(26):1905-11.

46 Thomas JW, Hofer TP. Accuracy of risk-adjusted mortality rate as a measure of hospital quality of care. Med Care 1999;37(1):83-92.

47 Rosenthal GE, Shah A, Way LE, et al. Variations in standardized hospital mortality rates for six common medical diagnoses: implications for profiling hospital quality. Med Care 1998;36(7):955-64.

48 Hannan EL, Bernard HR, O'Donnell JF, et al. A methodology for targeting hospital cases for quality of care record reviews. Am J Public Health 1989;79(4):430-6.

49 Lindley CM, Tully MP, Paramsothy V, et al. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 1992;21(4):294-300.

50 Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 1997;157(14):1531-6.

51 Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001;49(2):200-9.

52 Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA 2003;289(13):1652-8.

53 Gosney M, Tallis R. Prescription of contraindicated and interacting drugs in elderly patients admitted to hospital. Lancet 1984;2(8402):564-7.

54 Ray W, Federspiel C, Schaffner W. A study of antipsychotic drug use in nursing homes: epidemiologic evidence suggesting misuse. AJPH 1980;70(5):485-91.

55 Beers M, Ouslander J, Fingold S, et al. Inappropriate medication prescribing in skilled nursing facilities. Ann Intern Med 1992;117(8):684-9.

56 Williams B, Betley C. Inappropriate use of nonpsychotropic medications in nursing homes. J Am Geriatr Soc 1995;43(5):513-9.

57 Spore DL, Mor V, Larrat P, et al. Inappropriate drug prescriptions for elderly residents of board and care facilities. Am J Public Health 1997;87(3):404-9.

58 Aparasu RR, Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother 1997;31(7-8):823-9.

59 Mort JR, Aparasu RR. Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Arch Intern Med 2000;160(18):2825-31.

60 Aparasu RR, Sitzman SJ. Inappropriate prescribing for elderly outpatients. Am J Health Syst Pharm 1999;56(5):433-9.

61 U.S. General Accounting Office. Prescription drugs and the elderly: many still receive potentially harmful drugs despite recent improvement. Washington, DC: U.S. General Accounting Office; 1995. GAO Publication No. HEHS-95-152.

62 Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994;272(4):292-6.

63 Iezzoni L. Risks and outcomes. In: Iezzoni L, editor. Risk adjustment for measuring health outcomes. 2nd ed. Chicago, IL: Health Administration Press; 1997. p. 1-42.

64 Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001;286(4):415-20.

65 Leape LL. Error in medicine. JAMA 1994;272(23):1851-7.

66 Cooper JB, Gaba D. No myth: anesthesia is a model for addressing patient safety. Anesthesiology 2002;97(6):1335-7.

67 Leape LL. Reporting of adverse events. N Engl J Med 2002;347(20):1633-8.

68 Carter J. House passes bill to track medical errors. The Washington Post 2003 Mar 12.

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