Return to Never Events Collaborative
Never Events

  References:

  1. To Err Is Human: Building a Safer Health System. Kohn LT, Corrigan JM, and Donaldson MS, Editors. Institute of Medicine. National Academy Press. Washington D.C. 2000. http://www.nap.edu/openbook.php?isbn=0309068371

  2. Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April 2007. Volume 122. http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf

  3. CDC: Estimates of Healthcare-Associated Infections
    http://www.cdc.gov/ncidod/dhqp/hai.html

  4. Besser, RE. CDC’s Role in Preventing Healthcare Associated Infections http://appropriations.house.gov/Witness_testimony/LHHS/Richard_Besser_04_01_09.pdf

  5. Infections Due to Medical Care in Oregon Hospitals, 2003-2005 Oregon Health Policy and Research. Nov 2006 http://www.oregon.gov/OHPPR/RSCH/docs/HAI111406.pdf

  6. 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. http://www.ncbi.nlm.nih.gov/pubmed/14532315

  7. Lucado J, Paez K, Andrews R and Steiner C. Adult Hosptiail Stays with Infections Due to Medical Care, 2007. Statistical Brief #94 Healthcare Cost and Utilization Project AHRQ Aug 2010 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf 

  8. Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, Whitley Rj, and the HAI Elimination White Paper Writing Group.  Moving toward elimination of healthcare-associated infections: A call to action. Infect Control Hosp Epidemiol. 2010 Oct;31:S42–S44.
    http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/RegulatoryIssues/
    CDC/AJIC_Elimin.pdf 

  9. Frieden TR, Maximizing Infection Prevention in the Next Decade: Defining the Unacceptable. Infect Control Hosp Epidemiol.  2010 Oct;31:S1–S3.
    http://www.journals.uchicago.edu/doi/full/10.1086/656002 

  10. Levinson, DR.  Adverse Events in Hospitals:  National Incidence Among Medicare Beneficiaries.  Nov. 2010  OEI-06-09-00090  Download Report

  11. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010 Nov 25;363(22):2124-34.
     http://www.nejm.org/doi/full/10.1056/NEJMsa1004404    http://www.ncbi.nlm.nih.gov/pubmed/21105794   

  12. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A and James BC.    ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured.  Health Affairs.  April 2011 vol. 30 no. 4 581-589.  http://content.healthaffairs.org/content/30/4/581.abstract

  13. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.   http://www.ncbi.nlm.nih.gov/pubmed/21460463