Centers for Medicare and Medicaid Services.Hospital-acquired conditions, statute regulations program instructions. http://www.cms.hhs.gov/HospitalAcqCond/02_Statute_Regulations_Program_Instructions.asp#TopOfPage . Accessed December 22, 2008.
2.
National Quality Forum.Serious reportable events transparency & accountability are critical to reducing medical errors, fact sheet. http://www.qualityforum.org/projects/completed/sre/fact-sheet.asp. Accessed December 22, 2008.
3.
Centers for Medicare and Medicaid Services.Hospital-acquired conditions, overview. http://www.cms.hhs.gov/HospitalAcqCond/01_Overview.asp#TopOfPage. Accessed December 22, 2008.
4.
Centers for Medicare and Medicaid Services.CMS proposes three national coverage determinations to protect patients from preventable surgical errors [news release]. December 2, 2008 . http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3375&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrd . Accessed December 22, 2008.
5.
Kohn LT, Corrigan J, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. A Report of the Committee on Quality of Health Care in America. Washington, DC: National Academies Press; 1999.
6.
HealthPartners/ GHI.Provider information-administrative manual: never events . January 7, 2005. http://www.healthpartners.com/files/34581.pdf . Accessed December 22, 2008.
7.
Vesely R.Aetna to quit paying for "never events." Mod Healthc. January 15, 2008. http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080115/REG/524471875&SearchID=73339464098312.AccessedDecember22, 2008.
8.
The Leapfrog Group.More hospitals adopting Leapfrog Group's "never events" policy which includes apologies, reporting, and waiving costs [news release]. October 27, 2008 . http://www.leapfroggroup.org/media/file/NeverEvents2008.pdf. Accessed December 22, 2008.
9.
Department of Health and Human Services, Office of Inspector General.Adverse events in hospitals: overview of key issues. OEI-06-07-00470. Washington, DC: Department of Health and Human Services; December 2008.
10.
Agency for Healthcare Research and Quality.Morbidity & mortality rounds on the web. Perspectives on safety. Prevention of urinary tract infections: lessons for patient safety. http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=67 . Accessed December 22, 2008.
11.
Saint S., Wiese J., Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-480.
12.
Saint S., Kaufman SR, Thompson M., et al. A reminder reduces urinary catheterization in hospitalized patients . Jt Comm J Qual Patient Saf. 2005;31:455-462.
13.
Pronovost P. , Needham D., Berenholtz S., et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J. Med. 2006;355:2725-2732.