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101. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features The QSRS: Offers an expanded array of adverse event measures. … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event

102. Implementation Guide for the CANDOR Process: Appendix A | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apa.html
     August 01, 2022 - event: Number of adverse events reported >24 hours after occurrence Severity level of … adverse events reported. … Length of time it takes to disclose the event. … Length of time to complete investigation and analysis of the event. Number of claims asserted. … Determine a return on investment that ties to reduced adverse events.  

103. Building the Business Case for CANDOR Worksheet | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
     August 01, 2022 - event: Number of adverse events reported >24 hours after occurrence Severity level of … adverse events reported. … Length of time it takes to disclose the event. … Length of time to complete investigation and analysis of the event. Number of claims asserted. … Determine a return on investment that ties to reduced adverse events.  

104. Project Overview: Designing Consumer Reporting Systems for Patient Safety Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
     October 01, 2014 - Designing Consumer Reporting Systems for Patient Safety Events Current patient safety event … their family members are in a unique position to identify gaps in care that may have contributed to adverse … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse … Research to Create Patient Safety Event Reporting Systems for Consumers To develop recommendations

105. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - Methods Overview of event detection We developed a framework for automated event discovery from the … We studied event monitors, which can be used to deploy event detection logic in real time [9]. … Detecting Adverse Events Using Information Technology. … Policy and the Future of Adverse Event Detection Using Information Technology. … Using computerized data to identify adverse drug events in outpatients.

106. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect

107. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
     December 01, 2017 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … It is more difficult for staff to identify which residents are at risk for a future adverse event or … Investigate root causes when an adverse event occurs. … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed.

108. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     June 02, 2025 -  Nursing home staff generally do a good job of investigating and following up after an adverse event … These questions explore what the facility does to screen for risk of an adverse event. … Discussion questions are tailored to the On-Time adverse event of interest. … event of interest … The menu includes meetings directly related to the adverse event of interest, but additional uses of

109. Prologue: Laying the Foundation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
     June 02, 2025 - Challenges of reporting quickly give rise to challenges of encoding and organizing the adverse event … Strategies and efforts aimed at adverse event surveillance, creating useable taxonomies, and addressing … Another paper examines the perceptions of health care leaders and news media professionals related to adverse … event reporting. … Risk is treated by safety scientists as the likelihood that exposure to a hazard will lead to adverse

110. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
     January 01, 2024 - Aim 3: Hospital leaders think mandatory reporting discourages adverse event reporting in their hospitals … The adverse event was assigned to one of 19 categories. … All physician reviewers were asked to state if an adverse event, defined as an injury due to medical … Adverse drug events were the highest type of adverse event reported by patients and recorded in the … The longer patients stayed in the hospital, more patients reported having at least one adverse event

111. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
     August 01, 2022 - Each of the hospitals worked with the Department of Health staff to diagram how an adverse event involving … Communication that an adverse event occurred was documented in 79 percent of cases, with explanations … Participants discussed aspects of “involving patients as partners” after an adverse event, including … Interviews with Patients and Family Members Who Had Experienced Medical Harm After Adverse Event. … event that occurred and divides by the number of patients that had an adverse event; AHRQ Patient Safety

112. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
     January 01, 2021 - OR UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OR UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OR UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … (EVENT TYPE) excluded adverse events not associated with the birthing process or with an intrauterine … (EVENT TYPE) excluded adverse events not associated with the birthing process or with intrauterine

113. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
     April 01, 2025 - Thus, a subcategory of adverse events ascribed to error or substandard care, called preventable adverse … event 16 was introduced and defined as diagnostic errors that cause harm. … In these cases, specific events cause harm that is independent of the underlying disease and the event … Few investigators focus on these types of diagnostic adverse events. … The triggering event may not be visible or attributed to a single event or moment in time.

114. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse … event specifically related to communication failures in the ICU-to-ward transition. … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … , with more than one-third of these adverse events deemed preventable. 63 These adverse events are associated … event related to the ICU-ward handoff, and most of these adverse events were rooted in communication

115. 1 Preventablehospitaledvisits-Overview-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
     June 02, 2025 - • Nursing home staff generally do a good job of investigating and following up after an adverse event … These questions explore what the facility does to screen for risk of an adverse event. … event of interest. … Discussion questions are tailored to the On-Time adverse event being addressed. … The menu includes meetings directly related to the adverse event of interest, but additional uses of

116. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
     May 01, 2017 - Summary of impact on maternal and neonatal adverse events for L&D units submitting adverse event data … composite measures of maternal and neonatal adverse events, two maternal adverse event measures, two … neonatal adverse event measures, and one inpatient quality reporting measure. … Summary of impact on maternal and neonatal adverse events for L&D units submitting adverse event data … Summary of impact on maternal and neonatal adverse events for L&D units submitting adverse event data

117. AHRQ Safety Program For Long-Term Care: CAUTI
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
     March 01, 2017 - Events Adverse event: An injury to a resident caused by medical intervention rather than by the underlying … events happen  When an adverse event occurs, it can be difficult for a care provider to take ownership … event is essential AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Long-Term Care Safety Modules … Immediate Response to an Adverse Event Next Steps in Responding to an Adverse Event Care for the resident … Event Speak slowly and use clear language Give an advance alert (“I’m afraid I have some  news to share

118. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
     September 01, 2024 - Patient and Workforce Safety —an initiative led by AHRQ on behalf of HHS—will be highlighted at the event … A notable example is the recent release of  Adverse Events Among In-Hospital Medicare Patients in 2021 … The QSRS is a new one-of-a-kind national repository that includes data on 41 types of adverse events … event per hospital stay, with 83.6 adverse events per 1,000 discharges. … These rates improved in 2022, decreasing to 6.2 percent of patients and 71.1 adverse events per 1,000

119. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - (The abbreviation AE will be used throughout the paper to denote “adverse event,” “medical error,” etc … of serious injury or disability”); and Class C (an adverse event that “resulted in or is associated … Connecticut requires “a hospital or outpatient surgical facility … to report any adverse event to the … errors and preventable adverse events, and 3 years of adverse event reports to the New York Patient … event,” and from whose perspective—the physician, health plan, or patient—is the event adverse.

120. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - Woolever Abstract Background: In response to the occurrence of a sentinel event—a medical error with … event, or a sentinel event. … An adverse event has minimal effect on the involved patient and does not result in any significant … Total number of incident reports and number categorized as “near miss,” “adverse event,” or “sentinel … 200 250 300 Total Rep Near Miss Adv Event Sent Event 1998 2001 Advances in Patient Safety: Vol