Scanning the Headlines: Patient Safety
Updated on April 7, 2015
Click here for Patient Safety Archive Bibliography
Links to full-text articles are provided where available.
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Barr. P. (2015, Apr. 1). Hospitals play big role in plan to battle antibiotic resistence. H&HN Daily. Retrieved from: http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2015/April/antibiotic-action-plan-hospitals-blog-barr
Gapinski, K. (2015, January 22). Unfiltered OR lights burn patients at Oregon Hospital. Outpatient Surgery Magazine. Retrieved from: http://www.outpatientsurgery.net/outpatient-surgery-news-and-trends/general-surgical-news-and-reports/unfiltered-or-lights-burn-patients-at-oregon-hospital--01-22-15
Singh, H., and Sittig, D. (2015, January 14). Advancing the science of measurement of diagnostic errors in healthcare: the safer Dx framework. BMJ Quality and Safety. Retrieved from: http://qualitysafety.bmj.com/content/early/2015/01/14/bmjqs-2014-003675.full
(2015, Jan.). Preventing Delays in Treatment. Oakbrook Terrace, IL: Joint Commission. Retrieved from: http://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_Nine_Jan_2015_FINAL.pdf
Study: new approach to handoffs slashes errors, preventable adverse events; other medical centers move to implement the protocol. (2015, Jan.). ED Management, 27(1), 6-8.
2014-15 Targeted Medication Safety Best Practices for Hospitals. Institute for Safe Medication Practices, 2014-15. http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
(2015). Overview I Medication Reconciliation Implementation Toolkit. Philadelphia, PA: Society of Hospital Medicine (SHM). Retrieved from: http://www.hospitalmedicine.org/MARQUIS
Rice, S. (2014, Dec. 8). Despite progress on patient safety, still a long way across the chasm. Modern Healthcare, 44(49), 8-9.
Everhart, D., Shumaker, J.R., Duncan, R.P., Hall, A.G., Neff, D.F., and Shorr, R.I. (2014, Oct.-Dec.). Determinants of hospital fall rate trajectory groups: A longitudinal assessment of nurse staffing and organizational characteristics. Health Care Management Review, 39(4), 352-360.
Patient safety systems: New Accreditation Manual chapter for hospitals. (2014, Nov.). The Joint Commission Perspectives, 34(11), 1, 3-4.
Vesely, R. (2014, Nov.). Lasting lessons on reducing patient harm. H&HN. Hospitals & Health Networks, 88(11), 26-31. http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2014/Nov/fea-hospital-engagement-networks
Shinkman, R. (2014, October 20). Texas Health Presbyterian takes financial hit for Ebola screw-ups. FierceHealthFinance. Retrieved from: http://www.fiercehealthfinance.com/story/texas-health-presbyterian-takes-financial-hit-ebola-screw-ups/2014-10-20
Paterson, C., Miller, K., Benden, M., Shipp, E., Pickens, A., Wendel, M., and Pronovost, P. (2014, Oct.). The Safe Day Call: Reducing silos in health care through frontline risk assessment. The Joint Commission Journal on Quality and Patient Safety, 40(10), 476-479.
Safe and sound: informed design approaches help to prevent patient harm. (2014, Oct.). H&HN. Hospitals & Health Networks, 88(9), 55-56, 58, 60.
Shaw, R.E., and Litman, R.S. (2014, Oct.). Medication safety in the operating room: A survey of preparation methods and drug concentration consistencies in children’s hospitals in the United States. The Joint Commission Journal on Quality and Patient Safety, 40(10), 471-475.
Reveals, K., and others. (2014, October). The rise in clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010. American Journal of Infection Control. 42(10), 1028-1032. Retrieved from http://www.ajicjournal.org/article/S0196-6553(14)00898-0/abstract
Dollarhide, A.W., Rutledge, T., Weinger, M.B., Fisher, E.S., Jain, S., Wolfson, T., and Dresselhaus, T.R. (2014, Sept.-Oct.). A real-time assessment of factors influencing medication events. Journal for Healthcare Quality, 36(5), 5-12.
Hoppes, M., and Mitchell, J. (2014, September 30). Series Safety Events: A Focus on Harm Classification: Deviation in Care as Link Getting to Zero™ White Paper Series - Edition No. 2. Chicago: American Society for Healthcare Risk Management. Retrieved from: http://www.ashrm.org/ashrm/education/development/monographs/white-papers/SSE-2_getting_to_zero-9-30-14.pdf
Burmahl, B. (2014, Sept.). Breaking the chain of infection: MD Anderson’s ES team steps up fight to protect patients. Health Facilities Management, 27(9), 23-25.
Conway, L.J., Riley, L., and others. (2014, September). Implementation and impact of an automated group monitoring and feedback system to promote hand hygiene among health care personnel. The Joint Commission Journal on Quality and Patient Safety. 40(9), 408-417.
McKaig, D, Collins, C., and Elsaid, K.A. (2014, September). Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. The Joint Commission Journal on Quality and Patient Safety. 40(9), 398-407.
Mitchell, M.D., and Lavenberg, J.G. (2014, September). Hourly rounding to improve nursing responsiveness: a systematic review. JONA. The Journal of Nursing Administration. 44(9):462-472.
Patient safety, satisfaction rise to top of priority list. (2014, September). OR Manager, 30(9), 11-13, 15.
Pelletier, L.R., and Stichler, J.F. (2014, September). Patient-centered care and engagement: nurse leaders’ imperative for health reform. JONA. The Journal of Nursing Administration. 44(9):473-480.
Card, A.J. (2014, Quarter 3). Patient safety: this is public health. Journal of Healthcare Risk Management. 34(1), 6-12.
Groszkruger, D. (2014, Quarter 3). Diagnostic error: untapped potential for improving patient safety? Journal of Healthcare Risk Management. 34(1), 38-43.
Menon, S., Singh, H., and others. (2014, Quarter 3). Electronic health record-related safety concerns: a cross-sectional survey. Journal of Healthcare Risk Management. 34(1), 14-26.
Gapinski, K. Black box recorder on its Way. Outpatient Surgery Magazine. Aug. 25, 2014. http://www.outpatientsurgery.net/outpatient-surgery-news-and-trends/general-surgical-news-and-reports/black-box-recorder-on-its-way--08-25-14
Kuehn, B. Patient safety still lagging: advocates call for national patient safety monitoring board. JAMA. Aug. 20, 2014. http://jama.jamanetwork.com/data/Journals/JAMA/0/jmn140070.pdf
Rice, S. (2014, August 18). The human factor: to improve patient safety, hospitals urged to adjust for how staff use new technology. Modern Healthcare. 44(33), 12-15.
Putre, L. The AHA McKesson quest for quality prize winner. H&HN. Aug. 12, 2014. http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2014/Aug/fea-quest-for-quality-prize_VCU&utm_source=daily
(2014, August). Empowering everyone to build a culture of safety. H&HN. Hospital & Health Networks. 88(8), 45.
Lorenzi, N. (2014, August). Hand-hygiene monitoring: electronic compliance systems use technology to help prevent infections. Health Facilities Management. 27(8), 41-44.
Putting patient safety first with hard data and enlightening stories; and, An eagle eye on quality improvement; and, Broadening the scope of patient partnerships; and, Deep dives into close calls; and, When ideas emerge from the front lines, leaders listen. (2014, August). H&HN. Hospital & Health Networks. 88(8), 28-33.
Mixon, A., and others. Characteristics associated with post discharge medication errors. Mayo Clinic Proceedings. 89(8):1042-51, Aug. 2014. http://www.mayoclinicproceedings.org/article/S0025-6196%2814%2900387-5/abstract
Menon, S., and others. Electronic health record–related safety concerns: A cross-sectional survey. Journal of Healthcare Risk Management. 34(1):14–26, Aug. 2014. http://onlinelibrary.wiley.com/doi/10.1002/jhrm.21146/abstract
Groszkruger, D. Diagnostic error: Untapped potential for improving patient safety? Journal of Healthcare Risk Management. 34(1): 38-43, Aug. 2014. http://onlinelibrary.wiley.com/doi/10.1002/jhrm.21149/abstract
ED-based pharmacists make a big dent in medication errors. ED Management. 26(8):91-94, Aug. 2014.
The Joint Commission cracks down on vial misuse in hospitals. ED Management. 26(8):85-96, Aug. 2014.
Hardmeier, A., Tsourounis, C., and others. (2014, July-August). Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. Journal for Healthcare Quality. 36(4), 54-63.
Fibuch, E., and Ahmed, A. The role of failure mode and effects analysis in health care. PEJ. Physician Executive. 40(4):28-32, July-Aug. 2014.
Kalb, C. How a team of doctors at one hospital boosted hand washing, cut infections and created culture of safety. Yahoo News. July 21, 2014. http://news.yahoo.com/clean-hands--vanderbilt-s-hand-washing-initiative-172312795.html
Sullivan, K. Tennessee hospital drastically dropped infection rates through hand-hygiene initiative. FireceHealthcare. July 21, 2014. http://www.fiercehealthcare.com/story/tennessee-hospital-drastically-dropped-infection-rates-through-hand-hygiene/2014-07-21
Carlson, J., and Rice, S. All of a sudden, there was fire. Modern Healthcare. 44(28):8-9, July 14, 2014.
Project Evaluation Activity in Support of Partnership for Patients: Task 2 Evaluation Progress Report. Phoenix, AZ: (HSAG) Health Services Advisory Group. July 10, 2014. http://innovation.cms.gov/Files/reports/PFPEvalProgRpt.pdf
Rowlands, J., and others. Video observation to map hand contact and bacterial transmission in operating rooms. AJIC: American Journal of Infection Control. 42(7):698-701, July 2014. http://www.ajicjournal.org/article/S0196-6553(14)00137-0/fulltext
Talking Medicare's hospital fines for too many patient injuries. Kasier Health News. June 23, 2014. http://capsules.kaiserhealthnews.org/index.php/2014/06/talking-medicares-hospital-fines-for-too-many-patient-injuries/
Herzig, C., and others. State-Mandated Reporting of Health Care–Associated Infections in the United States: Trends Over Time. American Journal of Medical Quality, first published on June 20, 2014. http://ajm.sagepub.com/content/early/2014/06/20/1062860614540200.abstract
Clark, C. Preventable deaths report not ready for prime time. HealthLeaders Media. June 19, 2014. http://www.healthleadersmedia.com/page-1/QUA-305699/Preventable-Deaths-Report-Not-Ready-for-Prime-Time
Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert, no. 52, June 16, 2014. http://www.jointcommission.org/assets/1/6/SEA_52.pdf
Joint Commission. Sentinel Event Alert Issue 52: Preventing Infection from the Misuse of Vials. June 16, 2014. http://www.jointcommission.org/sea_issue_52/
Scott, R.D., II, Sinkowitz-Cochran, R., Wise, M.E., Baggs, J., Goates, S., Solomon, S.L., … Jernigan, J.A. (2014, June). CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990-2008. Health Affairs, 33(6), 1040-1047.
Mardon, R., and others. AHRQ's Clinical Decision Support Demonstration Projects. Rockville, MD: Agency for Healthcare Research and Quality. June 2014. http://healthit.ahrq.gov/sites/default/files/docs/page/findings-and-lessons-from-clinical-decision-support-demonstration-projects.pdf
Beyond the rubber stamp: energizing your EOC committee. Inside ASHE:57-58, Summer 2014.
Staying in compliance with OSHA’s hazard communication standard. Inside ASHE:59-62, Summer 2014.
A risk analysis of the steam sterilization process can improve patient safety. OR Manager. 30(6):24-25, 28, June 2014.
Donaldson, N., Aydin, C., and Fridman, M. Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. JONA. The Journal of Nursing Administration. 44(6):353-361, June 2014.
Turn OR staff into ‘legal eagles’ to track unusual occurrence. OR Manager. 30(6):1, 6-7, June 2014.
Eagle A. Safe and sound: Informed design approaches help to prevent patient harm. Health Facilities Management, June 2014. http://www.hfmmagazine.com/display/HFM-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HFM/Magazine/2014/June/coverstory-safe-and-sound-HAIs-alth-care-design
Haskell, H. Perspective: Patient advocacy in patient safety: have things changed? Web M&M [Agency for Healthcare Research and Quality], June 2014. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=160
Anderson, D., and others. SHEA/IDSA practice recommendation: Strategies to prevent surgical site infections: 2014 update. Infection Control and Hospital Epidemiology, 35(6):605-627, June 2014. http://www.jstor.org/stable/10.1086/676022
Hines, S. Advances in the Prevention and Control of HAIs: Strengthening National Efforts to Reduce Healthcare-Associated Infections. Rockville, MD: Agency for Healthcare Research and Quality, June 2014. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-hai/hai-article2.html
Dubberke, E., and others. SHEA/IDSA practice recommendation: Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(6):628-645, June 2014. http://www.jstor.org/stable/10.1086/676023
Tarrago, R., Nowak, J.E., and others. (2014, June). Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit. The Joint Commission Journal on Quality and Patient Safety. 40(6), 270-278.
Daly, B., and Mort, E.A. (2014, May-June). A decade after To Err Is Human: what should health care leaders to doing? PEJ. Physician Executive. 40(3), 50-52, 54.
Dressler, R., Consiglio-Ward, L., and others. (2014, May-June). Safety sciences as second nature: training residents to use best practices instinctively to keep patients safe. PEJ. Physician Executive. 40(3), 66-69.
Wasserman, M., Renfrew, M.R., and others. Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field. Journal of Healthcare Quality. 36(3):5-16, May-June 2014.
Magill, S., and others. Multistate point-prevalence survey of health care-associated infections. New England Journal of Medicine. 370:1198-1208, Mar. 27, 2014. http://www.nejm.org/doi/full/10.1056/NEJMoa1306801
Data and statistics: HAI prevalence survey. Centers for Disease Control and Prevention, accessed May 21, 2014 at http://www.cdc.gov/HAI/surveillance/index.html
New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. Washington: U.S. Department of Health & Human Services, May 7, 2014. http://innovation.cms.gov/Files/reports/patient-safety-results.pdf
Corley, D., Brockopp, D., and others. The Baptist Health high risk falls assessment: a methodological study. JONA. The Journal of Nursing Administration. 44(5):263-269, May 2014.
Jobe, L.L. Generational differences in work ethic among 3 generations of registered nurses. JONA. The Journal of Nursing Administration. 44(5):303-308, May 2014.
National Healthcare Quality Report 2013. No. 14-0005. Washington: U.S. Department of Health and Human Services, May 2014. http://www.ahrq.gov/research/findings/nhqrdr/nhqr13/2013nhqr.pdf
National and state healthcare associated infections progress report [based on 2012 data]. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Mar. 2014. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf
Yokoe, D., and others. SHEA/IDSA practice recommendation: Introduction to "A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5):455-459, May 2014. http://www.jstor.org/stable/10.1086/675819
Lo, E., and others. SHEA/IDSA practice recommendation: Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5):464-479, May 2014. http://www.jstor.org/stable/10.1086/675718
Safdar, N., and others. SHEA white paper: The evolving landscape of healthcare-associated infections: recent advances in prevention and a road map for research. Infection Control and Hospital Epidemiology, 35(5):480-493, May 2014. http://www.jstor.org/stable/10.1086/675821
Maggard-Gibbons M. The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program. BMJ Quality & Safety. Apr. 19, 2014. http://qualitysafety.bmj.com/content/early/2014/04/19/bmjqs-2013-002223.full
Singh, H., Meyer, A., and Thomas, E. The frequency of diagnostic errors in outpatient care: Estimations from three large observational studies involving US adult populations. BMJ Quality & Safety. 23:727-731, Apr. 17, 2014. http://qualitysafety.bmj.com/content/early/2014/04/04/bmjqs-2013-002627.abstract
Clarke, J.R. (2014, April). Is your office helping you prevent wrong site surgery? Bulletin of the American College of Surgeons. 99(4), 28-31.
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? Charting Nursing's Future. 22:1-8, Mar 14, 2014. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf411417
Soloman R. Measuring How Health IT Impacts Patient Safety [video]. H&HN Daily, Mar. 10, 2014. http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2014/Mar/031014-video-solomon-ecri-healthIT
Get Smart for Healthcare [antibiotic stewardship for hospitals]. Centers for Disease Control and Prevention, accessed Mar. 3, 2014 at http://www.cdc.gov/getsmart/healthcare/
Goffman, D., Brodman, M., and others. Improved obstetric safety through programmatic collaboration. Journal of Healthcare Risk Management;33(3):14-22, Q1 2014.
McKinney, M. Boston Children’s devises handoff procedures to reduce errors and improve patient safety. Modern Healthcare;44(9):29, Mar. 3, 2014.
Graber, M.L., Trowbridge, R., and others. The next organizational challenge: finding and addressing diagnostic error. The Joint Commission Journal on Quality and Patient Safety;40(3):102-110, Mar. 2014.
Siracuse, J.J., Benoit, E., and others. Development of a web-based surgical booking and informed consent system to reduce the potential for error and improve communication. The Joint Commission Journal on Quality and Patient Safety;40(3):126-133, Mar. 2014.
Studnicki, J., Ekezue, B.F., and others. Classification tree analysis of race- specific subgroups at risk for a central venous catheter-related bloodstream infection. The Joint Commission Journal on Quality and Patient Safety;40(3):134-143, Mar. 2014.
Singh, H. Editorial: helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. The Joint Commission Journal on Quality and Patient Safety;40(3):99-101, Mar. 2014.
Team participation and planning produce quality handoffs. OR Manager;30(3):1, 10-13, Mar. 2014.
Dalton, D., and Williams, N. Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid. London, UK: The Royal College of Surgeons of England; Mar. 2014. http://www.rcseng.ac.uk/policy/documents/CandourreviewFinal.pdf
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? Princeton, NJ: Robert Wood Johnson Foundation, Mar. 2014. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf411417
SIDM Patient Engagement Committee. Patient's Toolkit for Diagnosis. Society to Improve Diagnosis in Medicine. Mar. 2014. http://www.npsf.org/wp-content/uploads/2014/02/The-Patients-Toolkit-for-Diagnosis.pdf
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Safety Is Personal: Partnering With Patients and Families for the Safest Care. Boston, MA: National Patient Safety Foundation; Mar. 2014. http://www.npsf.org/about-us/lucian-leape-institute-at-npsf/lli-reports-and-statements/safety-is-personal-partnering-with-patients-and-families-for-the-safest-care/
DiCuccio, M. The relationship between patient safety culture and patient outcomes: a systematic review.
Journal of Patient Safety. Feb 27, 2014; [Epub ahead of print]. http://journals.lww.com/journalpatientsafety/pages/articleviewer.aspx?year=9000&issue=00000&article=99779&type=abstract
Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. National Alert Network. Horsham, PA: Institute for Safe Medication Practices. Feb. 18, 2014. http://www.ismp.org/nan/files/nan-20140218.pdf
Vaida, A., and others. Assessing the state of safe medication practices using the ISMP medication safety self assessment ® for hospitals: 2000 and 2011. Joint Commission Journal on Quality and Patient Safety. 40(2):51, Feb. 2014. http://www.ingentaconnect.com/content/jcaho/jcjqs/2014/00000040/00000002/art00001
Shieh, L, Chi, J., and others. Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. The Joint Commission Journal on Quality and Patient Safety;40(2):77-82, Feb. 2014.
Vaida, A.J., Lamis, R.L., and others. Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for hospitals: 2000 and 2011. The Joint Commission Journal on Quality and Patient Safety;40(2):51-67, Feb. 2014.
Bal, G., Sellier, E., and others. Improving quality of care and safety through morbidity and mortality conferences. Journal for Healthcare Quality;36(1):29-36, Jan.-Feb. 2014.
Denny, D.S., Allen, D.K., and others. The use of failure mode and effect analysis in a radiation oncology setting: the Cancer Treatment Centers of America experience. Journal for Healthcare Quality;36(1):18-28, Jan.-Feb. 2014.
Wang, Y., and others. National trends in patient safety for four common conditions, 2005-2011. New England Journal of Medicine. 370:341-351, Jan. 23, 2014. http://www.nejm.org/doi/full/10.1056/NEJMsa1300991
McKinney, M. (2014, January 20). The war on sepsis. Modern Healthcare. 44(3), 16-18.
Jayanthi, A. Joint Commission announces new patient safety goal. Becker's Clinical Quality & Infection Control. Jan. 6, 2014. http://www.beckersasc.com/asc-quality-infection-control/joint-commission-announces-new-patient-safety-goal.html
Kachalia, A., Little, A., and others. Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians. Health Affairs. 33(1):59-66, Jan. 2014.
Auer, C., Schwendimann, R., and Koch, R. How hospital leaders contribute to patient safety through the development of trust. JONA. Journal of Nursing Administration. 44(1):23-29, Jan. 2014.
Johnson, A.L., Jung, L., and Brown, K.C. Sleep deprivation and error in nurses who work the night shift. JONA. Journal of Nursing Administration. 44(1):17-22, Jan. 2014.
Action urged to prevent retained surgical items. (2014, January). Bulletin on the American College of Surgeons. 99(1), 53-54.
Vaughn T., Koepke, M., and Levey, S. Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes, and priorities in US hospitals. Journal of Healthcare Management. 59:111-128, 2014. http://ache.org/pubs/jhm/jhm_index.cfm
Committee on Diagnostic Errors in Medicine. Diagnostic Error in Medicine. Washington, DC: Institute of Medicine, 2014. http://www.iom.edu/activities/quality/diagnosticerrormedicine.aspx
Berenson, R., Upadhyay, D., and Kaye, D. Placing Diagnosis Errors on the Policy Agenda. Washington, DC: Urban Institute, 2014.
Medical Errors. A Report by the Staff of U.S. Senator Barbara Boxer. Washington: United States Senate, 2014. http://www.boxer.senate.gov/en/press/related/Medical_Errors_Report.pdf
Applying High Reliability Principles to Infection Prevention and Control in Long Term Care. Oakbrook Terrace, IL: Joint Commission, 2014. http://www.jointcommission.org/HRipcLTC.aspx