Note: The Institute of Medicine (IOM) has changed its name to the National Academy of Medicine. Because many of our references predate the name change, you will find IOM used here.

Ackroyd-Stolarz S. (2018). Improving the prevention of pressure ulcers as a way to reduce healthcare expenditures. CMAJ. 2014 Jul 8; 186(10): E370–E371. Retrieved January 25, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081234/.

Aebel ES, West JS. (2017). Client Alert: Florida Supreme Court Broadens Patient Access to Adverse Incident Reports. Retrieved January 12, 2019, from https://www.slk-law.com/NewsEvents/Publications/162511/Client-Alert-Florida-Supreme-Court-Broadens-Patient-Access-to-Adverse-Incident-Reports.

Agency for Healthcare Research and Quality (AHRQ). (2019). Never Events. Patient Safety Primer, Patient Safety Network. Retrieved January 12, 2019, from https://psnet.ahrq.gov/primers/primer/3.

Agency for Healthcare Research and Quality (AHRQ). (2019a). Healthcare-Associated Infections. Patient Safety Primer, Patient Safety Network. Retrieved January 17, 2019, from https://psnet.ahrq.gov/primers/primer/7.

Agency for Healthcare Research and Quality (AHRQ). (2019b). Fatigue, Sleep Deprivation, and Patient Safety. Patient Safety Primer, Patient Safety Network. Retrieved January 24, 2019, from https://psnet.ahrq.gov/primers/primer/37/
Fatigue-Sleep-Deprivation-and-Patient-Safety.

Agency for Healthcare Research and Quality (AHRQ). (2019c). Root Cause Analysis. Patient Safety Primer. Retrieved January 25, 2019, from https://psnet.ahrq.gov/primers/primer/10/Root-Cause-Analysis.

Agency for Healthcare Research and Quality (AHRQ). (2019d). AHRQ Analysis Finds Hospital-Acquired Conditions Declined by Nearly 1 Million from 2014-2017: HHS Initiatives Continue to Improve Patient Safety. Press Release. January 29, 2019. Retrieved January 30, 2019, from https://www.ahrq.gov/news/newsroom/press-releases/hac-rates-declined.html.

Agency for Healthcare Research and Quality (AHRQ). (2019e). AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014–2017. Retrieved January 30, 2019, from https://www.ahrq.gov/sites/default/files/wysiwyg/
professionals/quality-patient-safety/pfp/hacreport-2019.pdf.

Agency for Healthcare Research and Quality (AHRQ). (2019f). Declines in Hospital-Acquired Conditions. Infographic. Retrieved January 30, 2019, from https://www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf.

Agency for Healthcare Research and Quality (AHRQ). (2018). QI Guide on Improved Nursing Care: My Quality Improvement (MyQI). Retrieved January 12, 2019, from http://www.ahrq.gov/professionals/systems/monahrq/myqi/nursing.html. was 2015

Agency for Healthcare Research and Quality (AHRQ). (2018a). AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014–2016. Retrieved January 17, 2019, from https://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html AND https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf.

Agency for Healthcare Research and Quality (AHRQ). (2018b). Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. Content last reviewed July 2018. Retrieved January 19, 2019, from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html.

Agency for Healthcare Research and Quality (AHRQ). (2018c). 20 Tips to Help Prevent Medical Errors. Retrieved January 25, 2019, from http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html.

Agency for Healthcare Research and Quality (AHRQ). (2018d). Making Healthcare Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Retrieved January 24, 2019, from http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

Agency for Healthcare Research and Quality (AHRQ). (2018e). Tampa Hospital Uses AHRQ Tools to Reduce Emergency Department CAUTI Rates by 75 Percent. Patient Safety Impact Case Studies. December 2018. Retrieved January 30, 2019, from https://www.ahrq.gov/news/newsroom/case-studies/201808.html.

Agency for Healthcare Research and Quality (AHRQ). (2017). Guide to Patient and Family Engagement in Hospital Quality and Safety. Retrieved January 21, 2019, from https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html.

Agency for Healthcare Research and Quality (AHRQ). (2015). Health Literacy Universal Precautions Toolkit, 2nd Edition. Retrieved January 24, 2019, from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.html.

Agency for Healthcare Research and Quality (AHRQ). (2013). Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. Retrieved July 27, 2015, from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html.

Agency for Healthcare Research and Quality (AHRQ). (2013a). Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Retrieved August 8, 2015, from http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.

Agency for Healthcare Research and Quality (AHRQ). (2009). Infants are at the Highest Risk for Errors Involving Cardiovascular drugs. Research Activities 2009; 351:3. Retrieved January 25, 2019, from http://archive.ahrq.gov/news/newsletters/research-activities/nov09/1109RA.pdf.

Agency for Healthcare Research and Quality Health IT (AHRQ HIT). (2008). Lean Six Sigma. Retrieved January 25, 2019, from http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/lean-six-sigma.

Alexander CA, Wang L. (2014). Medication Errors: Preventing Untimely Deaths. International Journal of Research in Nursing 2014; 5(2):52-60. Retrieved January 25, 2019, from http://thescipub.com/pdf/10.3844/ijrnsp.2014.52.60.

American Association of Clinical Chemistry (AACC). (2015). Laboratory Medicine: Advancing Quality in Patient Care. Retrieved January 19, 2019, from https://www.aacc.org/health-and-science-policy/aacc-policy-reports/2015/laboratory-medicine-advancing-quality-in-patient-care#2.

American Society for Quality (ASQ). (n.d.) Lean Six Sigma in Healthcare. Retrieved January 25, 2019, from
http://asq.org/healthcaresixsigma/lean-six-sigma.html.

Barach P. (2005). The Unintended Consequences of Florida Medical Liability Legislation. AHRQ: Patient Safety Network, Perspectives on Safety. Retrieved January 12, 2019 from https://psnet.ahrq.gov/perspectives/perspective/14/The-Unintended-Consequences-of-Florida-Medical-Liability-Legislation.

Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. (2017). Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–791. https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725.

Berry SD, and Kiel DP. (2018). Falls, Updated July 2018. Geriatrics Review Syllabus. Retrieved January 19, 2019, from https://geriatricscareonline.org/FullText/B023/B023_VOL001_PART001_SEC004_CH032.

Betancourt J, Renfrew M, Green A, et al. (2012). Background on Patient Safety and LEP Populations. In: Improving patient safety systems for patients with limited English proficiency: A Guide for Hospitals. Rockville (MD): Agency for Healthcare Research and Quality. AHRQ Publication No. 12-0041. Retrieved January 25, 2019, from http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguide1.html.

Bihari M. (2018) Health Insurance—Medical Errors and Health Reform: Affordable Care Act May Improve Patient Safety. verywellhealth.com. Retrieved January 12, 2019, from https://www.verywellhealth.com/medical-errors-and-health-reform-1738919.

Bird J. (2013). Survey: Nurse understaffing, fatigue threatens patient safety. Retrieved January 24, 2019, from https://www.fiercehealthcare.com/healthcare/survey-nurse-understaffing-fatigue-threatens-patient-safety#ixzz2PJOGqw2x.

Butler, Mary. (2015, July). Preventing healthcare's top four documentation disasters.  Journal of AHIMA 86(7):18–23. Retrieved January 25, 2019, from http://library.ahima.org/doc?oid=107687.

CBS Local Media. (2011). I Team: Ignoring Patients’ Right to Know. May 23, 2011. Retrieved January 21, 2019, from http://miami.cbslocal.com/2011/05/23/i-team-ignoring-patients-right-to-know/?sms_ss=facebook&at_xt=4de937af5b9c4b03%2C0.

Centers for Disease Control and Prevention (CDC). (2019). Clostridioides difficile Infection. Healthcare-associated Infections (HAI). Retrieved January 16, 2019, from https://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html.

Centers for Disease Control and Prevention (CDC). (2019a). What is C. diff? Clostridioides difficile (C. diff). Retrieved January 16, 2019, from https://www.cdc.gov/cdiff/what-is.html.

Centers for Disease Control and Prevention (CDC). (2018b). Data Highlights. Healthcare-Associated Infections (HAIs). Retrieved January 15, 2019, from https://www.cdc.gov/hai/data/portal/index.html.

Centers for Disease Control and Prevention (CDC). (2018c). Information for Clinicians about C. diff. Clostridioides difficile (C. diff). Retrieved January 16, 2019, from https://www.cdc.gov/cdiff/clinicians/index.html AND https://www.cdc.gov/cdiff/clinicians/faq.html.

Centers for Disease Control and Prevention (CDC). (2018d). Antibiotic/Antimicrobial Resistance (AR/AMR). Retrieved January 17, 2019, from https://www.cdc.gov/drugresistance/ AND https://www.cdc.gov/drugresistance/about.html.

Centers for Disease Control and Prevention (CDC). (2018e). Methicillin-resistant Staphylococcus aureus (MRSA). Retrieved January 17, 2019, from https://www.cdc.gov/mrsa/index.html AND https://www.cdc.gov/mrsa/healthcare/index.html.

Centers for Disease Control and Prevention (CDC). (2018f). Hand Hygiene in Healthcare Settings. Retrieved January 18, 2019, from https://www.cdc.gov/handhygiene/index.html.

Centers for Disease Control and Prevention (CDC). (2018g). Healthcare Providers. Hand Hygiene in Healthcare Settings. Retrieved January 18, 2019, from https://www.cdc.gov/handhygiene/providers/index.html.

Centers for Disease Control and Prevention (CDC). (2018h). Clinical Laboratory Improvement Amendments (CLIA). Retrieved January 19, 2019, from https://wwwn.cdc.gov/clia/About.aspx and https://wwwn.cdc.gov/clia/Regulatory/default.aspx.

Centers for Disease Control and Prevention (CDC). (2018j). Waived Tests. Clinical Laboratory Improvement Amendments (CLIA). Retrieved January 21, 2019, from https://wwwn.cdc.gov/clia/resources/waivedtests/default.aspx#.

Centers for Disease Control and Prevention (CDC). (2018k). Medication Safety Program: For Parents: Young Children and Adverse Drug Events. Retrieved January 24, 2019, from https://www.cdc.gov/MedicationSafety/parents_childrenAdverseDrugEvents.html.

Centers for Disease Control and Prevention (CDC). (2018m). Adverse Drug Events in Adults. Medication Safety Program. Retrieved January 25, 2019, from https://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html.

Centers for Disease Control and Prevention (CDC). (2017). Leading Causes of Death. Retrieved January 11, 2019, from http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm AND https://www.cdc.gov/nchs/data/dvs/LCWK9_2015.pdf.

Centers for Disease Control and Prevention (CDC). (2017a). Catheter-Associated Urinary Tract Infections (CAUTI). Healthcare-Associated Infections. Retrieved January 16, 2019, from https://www.cdc.gov/hai/ca_uti/uti.html.

Centers for Disease Control and Prevention (CDC). (2017b). Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) (last updated 2017). Retrieved January 16, 2019, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf.

Centers for Disease Control and Prevention (CDC). (2017c). Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 (last updated 2017). Retrieved January 16, 2019, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf.

Centers for Disease Control and Prevention (CDC). (2017d). Important Facts about Falls. Older Adult Falls. Home & Recreational Safety. Retrieved January 19, 2019, from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.

Centers for Disease Control and Prevention (CDC). (2016). Central Line-associated Bloodstream Infections. Healthcare-Associated Infections (HAI). Retrieved January 16, 2019, from https://www.cdc.gov/hai/bsi/bsi.html.

Centers for Disease Control and Prevention (CDC). (2016a). National and State Healthcare Associated Infections: 2016 Progress Report. Retrieved January 16, 2019, from https://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf.

Centers for Disease Control and Prevention (CDC). (2016b). Show Me the Science. Hand Hygiene in Healthcare Settings. Retrieved January 18, 2019, from https://www.cdc.gov/handhygiene/science/index.html.

Centers for Disease Control and Prevention (CDC). (2016c). Costs of Falls Among Older Adults. Home and Recreational Safety. Retrieved January 19, 2019, from https://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html.

Centers for Disease Control and Prevention (CDC). (2016d). Keep Them STEADI: Preventing Older Adult Falls in Hospital-Based Settings. Retrieved January 19, 2019, from https://www.cdc.gov/steadi/stories/hospital.html.

Centers for Disease Control and Prevention (CDC). (2015). State-based HAI prevention: Florida. Retrieved January 12, 2019, from https://www.cdc.gov/HAI/stateplans/state-hai-plans/fl.html. (No data updates since 2015. More current data at CDC, 2018 above.)

Centers for Disease Control and Prevention (CDC). (2015a). Frequently Asked Questions about Catheter-associated Urinary Tract Infections. Healthcare-Associated Infections (HAI). Retrieved January 16, 2019, from https://www.cdc.gov/hai/ca_uti/cauti_faqs.html.

Centers for Disease Control and Prevention (CDC). (2011). Resources for Patients and Healthcare Providers. Central Line-Associated Bloodstream Infections. Healthcare-Associated Infections (HAI). Retrieved January 16, 2019, from https://www.cdc.gov/HAI/bsi/CLABSI-resources.html.

Centers for Disease Control and Prevention (CDC). (2011a). VRE in Healthcare Settings. Retrieved January 17, 2019, from https://www.cdc.gov/HAI/organisms/vre/vre.html.

Centers for Disease Control and Prevention (CDC). (2010). Frequently Asked Questions About Surgical Site Infections. Healthcare-Associated Infections. Retrieved January 15, 2019, from https://www.cdc.gov/HAI/ssi/faq_ssi.html.

Centers for Disease Control and Prevention (CDC). (2010a). Frequently Asked Questions About Ventilator-Associated Pneumonia. Healthcare-Associated Infections (HAIs). Retrieved January 16, 2019, https://www.cdc.gov/HAI/vap/vap_faqs.html.

Centers for Medicare and Medicaid Services (CMS). (2018). Hospital-Acquired Conditions. Retrieved January 11, 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html AND https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html. AND HAI Data. Select your healthcare-associated infection (HAI) data for various healthcare settings. Retrieved January 12, 2019, from https://gis.cdc.gov/grasp/PSA/HAIreport.html.

Centers for Medicare and Medicaid Services (CMS). (2018a). Hospital-Acquired Condition Reduction Program (HACRP). Retrieved January 15, 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html. AND Medication Safety Basics. Retrieved January 14, 2019, from https://www.cdc.gov/medicationsafety/basics.html.

Center for Medicare/Medicaid Services (CMS). 2015). FY 2013, FY 2014, and FY 2015 Final HAC List. 2015, no changes have been made. Retrieved March 28 2019 from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/FY_2013_Final_HACsCodeList.pdf.

Child Health Patient Safety Organization (CHPSO). (2019).  2018 Annual Report. Retrieved March 28, 2019 from https://www.childrenshospitals.org/Site-Search?query=CHPSo+2018+Report.

Cho I, Park H, Choi Y, et al. (2014). Understanding the Nature of Medication Errors in an ICU with a Computerized Physician Order Entry System. PLoS ONE 9(12): e114243. Retrieved January 25, 2019, from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0114243.

Clinical Laboratory Improvement Amendments (CLIA). (2014). CLIA: Individualized Quality Control Plan: What is an IQCP? November 2014. Retrieved January 19, 2019, from https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIAbrochure13.pdf.

Commission on Office Laboratory Accreditation (COLA). (2015). A COLA White Paper: Federal Government Questions Quality in Waived Testing. Retrieved January 21, 2019, from https://www.cola.org/wp-content/uploads/2015/07/COLA_13147-White-paper_v5.pdf.

Currie L. (2008). Fall and Injury Prevention, Chapter 10. In Hughes RG, (ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality. Retrieved January 19, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK2653/.

Delbanco SF. (2014). The Payment Reform Landscape: Non-Payments. Health Affairs Blog September 4, 2014. Retrieved January 21, 2019, from https://www.healthaffairs.org/do/10.1377/hblog20140904.041220/full/.

Devine JG. (2015). Two Wrongs Don’t Make a Right (Kidney). Commentary. Spotlight Case. Retrieved January 25, 2019, from https://psnet.ahrq.gov/webmm/case/341/Two-Wrongs-Dont-Make-a-Right-Kidney?q=documentation+errors.

Englebright J, Westcott R, McManus K, Kleja K, et al. (2018). A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community Hospitals. Journal of Patient Safety 14(1):54–59, MAR 2018. DOI: 10.1097/PTS.0000000000000167. Retrieved January 25, 2019, from https://insights.ovid.com/crossref?an=01209203-201803000-00010.

Epner P, Gans J, Graber M. (2013). When Diagnostic Testing Leads to Harm: A New Outcomes-Based Approach for Laboratory Medicine. BMJ Quality & Safety 2013; 22(Suppl 2):ii6-ii10. Retrieved January 19, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3786651/.

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Florida Department of Health (FDOH). (2018). Healthcare-Associated Infections (HAI). Retrieved January 12, 2019, from http://www.floridahealth.gov/diseases-and-conditions/health-care-associated-infections/index.html.

Florida General Counsel’s Office (Florida General Counsel). (2008). Memo to Risk Managers re: Amendment 7 (July 1, 2008). Retrieved January 21, 2019, from http://www.fdhc.state.fl.us/SCHS/RiskMgtPubSafety/docs/articles/amendment7.pdf.

Florida House. (2009). Governmental Affairs Policy Committee Meeting packet. (March 4, 2009). Retrieved January 12, 2019, from http://www.flhouse.gov/SEctions/Documents/loaddoc.aspx?PublicationType=Committees&CommitteeId=2476&Session=2009&DocumentType=Meeting%20Packets&FileName=GovAffairsPolicyCom%2003-04-09.REVISED%20ONLINEpdf.pdf.

Florida Legislature, Office of Program Policy Analysis and Government Accountability (FL OPPAGA). (2006). Patient Safety Corporation Has Made Progress; Needs to Continue Developing Its Infrastructure. Report No. 06-87, December 2006. Retrieved January 12, 2019, from www.oppaga.state.fl.us/MonitorDocs/Reports/pdf/0676rpt.pdf.

Florida Senate. (2007). Florida Patient Safety Corporation. Interim Project Report 2008-136, November 2007. Retrieved January 21, 2019, from http://archive.flsenate.gov/data/Publications/2008/Senate/reports/interim_reports/pdf/2008-136hr.pdf.

Florida Senate. (2009). Bill Analysis and Fiscal Impact Statement (SB1896). Retrieved January 21, 2019, from http://archive.flsenate.gov/data/session/2009/Senate/bills/analysis/pdf/2009s1896.hr.pdf.

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Florida Senate. (2008). Open Government Sunset Review of Section 381.0273, F.S., Public Records and Meetings Exemptions for the Florida Patient Safety Corporation. Retrieved January 21, 2019, from http://archive.flsenate.gov/data/Publications/2009/Senate/reports/interim_reports/pdf/2009-212hr.pdf.

Florida Statutes. (2018). The 2018 Florida Statutes. 381.028: Adverse Medical Incidents. Retrieved January 12, 2019, from http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0381/Sections/0381.028.html.

Florida Statutes. (2018a). The 2018 Florida Statutes. 395.0197: Internal Risk Management Program. Retrieved January 12, 2019, from http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0395/Sections/0395.0197.html AND for details of changes in 2018: http://laws.flrules.org/2018/24.

Florida Statutes. (2018b). The 2018 Florida Statutes. 408.061: Data Collection. Retrieved January 12, 2019, from http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=hospital-acquired+infections&URL=0400-0499/0408/Sections/0408.061.html.

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Haymond S. (2016). What Everyone Should Know about Lab Tests: They aren’t always correct and they aren’t always useful. Guest Blog. Scientific American. May 9, 2016. Retrieved January 19, 2019, from https://blogs.scientificamerican.com/guest-blog/what-everyone-should-know-about-lab-tests/.

Hirschtick R. (2012). Sloppy and Paste. Web Morbidity & Mortality Rounds on the Web. July 2012. Agency for Healthcare Research and Quality. Retrieved January 25, 2019, from https://psnet.ahrq.gov/webmm/case/274.

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