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  1. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/index.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected eventsevents and a more proactive method to achieving an amicable and fair resolution for the patient/family … Care Video: Notification of Adverse Event Video: Planning for Meetings with Family Video: Disclosure
  2. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - ■ 44% of adverse events were preventable. … ■ Potential decrease in adverse events being litigated, which can potentially lead to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … Slide 16 6 – Facilitator Notes - Grand Rounds Presentation Say: A good response to adverse events … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events
  3. monahrq.ahrq.gov/hai/pfp/2014-final.html
    January 01, 2018 - events. … About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverseEvents Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that have implemented
  4. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers/pressure … For example, measured adverse drug events continued to drop from 2014 to 2017, while measured pressure … Preliminary 2017 2019 Goal (20% Reduction of each HAC) Adverse Drug Events 33.7 30.0 27.1 … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … Due to changes in how some conditions and adverse events are described in ICD-9 and ICD-10, the data
  5. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
    January 01, 2016 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers and falls … For example, measured adverse drug events continued to drop from 2014 to 2016, while measured pressure … Infections (CLABSI) Clostridium difficile Infections Falls Obstetric Adverse Events Pressure Ulcers … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS, including those in the Surgical … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number
  6. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
    January 01, 2011 - 10 20 30 40 50 Pe rc en t Type of Physical Harm Types of Physical Harm Experienced From Adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … http://teamstepps.ahrq.gov/� http://teamstepps.ahrq.gov/� Summary  Adverse events that affect LEP … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Causes of Adverse Events for LEP and Culturally Diverse Patients Systems and Strategies To Improve Safety
  7. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … Potential decrease in adverse events being litigated, which can lead potentially led to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm eventsevents really hinges on knowing about them immediately.
  8. monahrq.ahrq.gov/news/newsletters/e-newsletter/868.html
    June 01, 2023 - Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Did Not Adverse tracheal intubation-associated events—unwanted events that occur as a result of the … tracheal intubation-associated events. … events.
  9. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated
  10. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events? … Identification and Analysis of Actual and Potential Adverse Events: Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events? … Is an attempt made to disclose within the first 24 hours following an adverse event?
  11. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events?         … Identification and Analysis of Actual and Potential Adverse Events Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions?     … Do staff have access to a system for reporting adverse events?         … Is an attempt made to disclose within the first 24 hours following an adverse event?        
  12. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
    June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS AdverseEvents Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated
  13. monahrq.ahrq.gov/hai/pfp/haccost2017.html
    November 01, 2017 - Obstetric Adverse Events. Pressure Ulcers. Surgical Site Infections. … Bloodstream Infections          Falls          Obstetric Adverse Events          Pressure Ulcers … Central Line-Associated Bloodstream Infections Falls Obstetric Adverse Events Pressure Ulcers … Stream Infections (CLABSI) Falls Obstetric Adverse Events (OBAE) Pressure Ulcers Surgical Site … Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/or
  14. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … their institutions include how to: Engage patients and families in disclosure communication following adverseevents. … Implement a Care for the Caregiver program for providers involved in adverse events. … Investigate and analyze an adverse event to learn from it and prevent future adverse events.
  15. monahrq.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
    October 01, 2015 - events—such as adverse drug events, falls, and pressure ulcers—occurred. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.
  16. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Disclosure communication following an adverse event should include answers to the following questions … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of
  17. monahrq.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … Events Associated With Hip Joint Replacements 16,000 0.49 MPSMS (2015) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented
  18. monahrq.ahrq.gov/data/resources/index.html
    April 28, 2024 - Data Resource Name Search   Filter by Topic Access to Care (4) AdverseEvents (1) Ambulatory (2) By Payer (2) By State (3) Children (3) Children (1) … HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about adverseevents and patient safety-related events in U.S. hospitals. … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries
  19. monahrq.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
    December 01, 2012 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: Systems … Identify common causes of adverse events for LEP and culturally diverse patients. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Return to Contents Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Use … Language proficiency and adverse events in U.S. hospitals: a pilot study.
  20. monahrq.ahrq.gov/hai/hac/tools.html
    March 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … To reduce these HACs and other adverse events in hospitals, frontline clinicians and others use many … Antibiotic use:  Toolkit To Improve Antibiotic Use in Acute Care Hospitals Adverse drug events: Medications … ICUs Medical devices: Toolkit for Decolonization of Non-ICU Patients With Devices Obstetrical adverseevents: Toolkit for Improving Perinatal Safety Pressure ulcers: Preventing Pressure Ulcers in Hospitals

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