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41. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
    January 01, 2024 - Scope: The National Action Plan for Adverse Drug Event (ADE) Prevention identified three high-priority … Drug Event Prevention: Targeting High-Risk Drug Classes: The National Action Plan for Adverse Drug … drug events or potential adverse drug events by the physician reviewers. … The combined incidence rate of adverse drug events and potential adverse drug events in the intervention … Adverse drug events resulting from patient errors in older adults.

42. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - Scope and Significance Preventable Adverse Drug Events in Community Pharmacies Adverse drug events (ADEs … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Incidence of adverse drug reactions in hospitalized patients. … Adverse drug events in ambulatory care.

43. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
    February 21, 2008 - The cost of treating an adverse drug event in a hospital averages $3,244 to $5,857 per case.47, 48, … 49, 50 3 Adverse Drug Events: Common, Serious, and Costly Adverse drug events (ADEs) are the … Adverse drug reactions as cause of admission to hospital: Prospective analysis of 18,820 patients. … The costs of adverse drug events in hospitalized patients. … Can the frequency and risks of fatal adverse drug events be determined?

44. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
    January 01, 2024 - drug events. … Key words: probabilistic risk assessment, adverse drug events, ambulatory setting 2 Purpose In our … previous study of preventable adverse drug events among 30,000 older adults treated in the ambulatory … setting by a multispecialty group practice over a 1-year period,1 we found a rate of adverse drug events … of 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years

45. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
    January 01, 2007 - Incidence of adverse drug events and potential adverse drug events. JAMA 1995; 274: 29-34. 5. … The incident reporting system does not detect adverse drug events: A problem for quality improvement

46. Serious Reportable Adverse Events in Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
    December 01, 2000 - Serious Reportable Adverse Events in Health Care 339 Serious Reportable Adverse Events in Health Care Kenneth W. Kizer, Melissa B. Stegun Abstract Health care errors resulting in patient harm are a leading cause of morbidity and mortality in the United States, although there is no national reporting of such…

47. Declines in Hospital-Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
    January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,500 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections

48. Declines in Hospital-Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
    January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections -37%

49. Prologue: Technology and Medication Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
    June 02, 2025 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … drug events; reduce costs through streamlining processes and providing more targeted, efficient care … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … drug events, ranging from increased involvement of pharmacists, to e-prescribing technologies, to computer-based … drug events.

50. ChartBook On Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
    March 04, 2016 - drug event … Drug Events With Warfarin Hospitalized adult patients with an anticoagulant-related adverse drug event … drug event … Medication errors do not include adverse drug reactions. … Drug Events Measures of Patient Safety in the Hospital Setting: Adverse Drug Events Patient Safety

51. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    April 01, 2025 - Using MPSMS data, AHRQ determined that national efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014

52. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - (PDF, 11.1 MB) Text Description: National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease.

53. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
    November 01, 2017 - Adverse Drug Events (anticoagulants, opioids, and hypoglycemic agents) 2. … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[ … Clinical and economic impact of adverse drug reactions in hospitalized patients. … Adverse Drug Events Exhibit D2. Catheter-Associated Urinary Tract Infection Exhibit D2.

54. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
    November 01, 2017 - Adverse Drug Events (anticoagulants, opioids, and hypoglycemic agents) 2. … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[ … Clinical and economic impact of adverse drug reactions in hospitalized patients. … Adverse Drug Events Exhibit D2. Catheter-Associated Urinary Tract Infection Exhibit D2.

55. Final Progress Report: Drug-Drug Interaction Clinical Decision Support Conference Series (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/malone-report.pdf
    January 01, 2024 - Injury due to a known DDI is a preventable adverse drug event and constitutes a serious medication … Injury due to a known DDI is a preventable adverse drug event and serious medication error. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Drug-drug interactions among elderly patients hospitalized for drug toxicity. … Gender differences in drug toxicity. Trends Pharmacol Sci. Mar 2010;31(3):108-114.

56. Final Progress Report: Transforming the Medication Regimen Review Process of High-Risk Drugs Using a Patient-Centered, Telemedicine-Based Approach to Prevent ADEs in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/kane-gill-report.pdf
    January 01, 2024 - Adverse drug event, telemedicine, nursing home, pharmacist Purpose We conducted a quality improvement … The National Action Plan for Adverse Drug Event Prevention identified the nearly 16,000 NHs as a clinical … Post-admission Alerts Evaluated for Adverse Drug Events Telemedicine Communications. … Drug Reaction Probability Scale. … Adverse drug events were defined as injuries resulting from a medication.

57. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
    January 01, 2024 - drug events. … Although an adverse drug event in this setting may be directly linked to a “human error,” the root cause … Relationship between Nurse Staffing, Health Inspection Deficiencies and Adverse Drug Events in Nursing … drug event incidence. … Dementia and the Incidence of Adverse Drug Events in the Nursing Home.

58. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
    January 01, 2024 - drug events (p=0.020). … In other chronic disease states, adverse drug events have been clearly established as a major risk factor … Therefore, early recognition of adverse drug events in kidney transplant recipients will likely help … drug events. … Incidence and impact of adverse drug events contributing to hospital readmissions in kidney transplant

59. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
    January 01, 2004 - Timely analysis of such feedback revealed omissions of medications, diagnoses, and adverse drug reactions … Similarly, “missing” adverse drug reactions noted by clinicians were confirmed by chart review as not … One comment highlighted an instance where an adverse drug reaction (ADR) reaction to a substance was … Incorrect adverse drug reaction (ADR) notification 1 Error in the data conversion, leading to the

60. Clinical Pharmacists in Emergency Medicine (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
    February 21, 2008 - adverse drug events that occur in the ED are a significant public health problem and need to be reduced … Adverse drug events in emergency department patients. Ann Emerg Med 2002; 39: 258-267. 1. … Systems analysis of adverse drug events. ADE Prevention Study Group. … Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. … The clinical pharmacist’s role in preventing adverse drug events.