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141. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
     July 01, 2023 - But clarity of language does not necessarily help respondents determine whether an adverse event experienced … The Challenge: Most studies eliciting patient experience with medical errors focus on the adverse event … The focus of questions is on the immediate antecedents and outcomes of the adverse event. … event. … Families as partners in hospital error and adverse event surveillance.

142. Understanding SOPS Surveys: A Primer for New Users - Famolaro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-4-famolaro-2018.pdf
     January 01, 2018 - event rates • Nursing Home SOPS to CMS Nursing Home Compare Five-Star Ratings 44 Hospital SOPS … Hospital SOPS & PSI Adverse Event Rates Higher patient safety culture scores associated with lower … adverse event rates r = -.36 0 2 4 6 8 10 12 14 16 18 40% 45% 50% 55% 60% 65% 70% 75% 80% … Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events. … Event Rates Nursing Home SOPS and CMS Nursing Home Compare 5-Star Ratings SOPS Technical Assistance

143. Is There an Association Between Patient Safety Indicators and Hospital Teaching Status? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
     April 28, 2008 - The AHRQ PSIs are based on the Institute of Medicine (IOM) definition of an adverse event: “Injury … The Harvard Medical Practice Study, using chart-abstracted data, found lower adverse event rates in … event rates. … event rates. … In addition, if higher risk-adjusted adverse event rates are, in fact, associated with the presence

144. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
     August 01, 2022 - event investigation and remediation. … event reporting, including reductions of approximately 42% in the number of claims, 51% in the costs … Development of an adverse event debriefing method Based on 62 interviews conducted using a debriefing … events that is not otherwise known to those analyzing the event. … event.

145. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
     May 01, 2017 - Is it possible to intervene before adverse events occur? … event. … Investigate the root cause when an adverse event occurs. … The questions in each Self-Assessment Worksheet are tailored to the On-Time adverse event being addressed … event of interest.

146. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
     September 01, 2014 - Drug Event (ADE) MPSMS ADE Associated With Digoxin MPSMS ADE Associated With Hypoglycemic Agents MPSMS … than as a rate for the subpopulation that has the opportunity to experience the adverse event. … MPSMS data are used, we multiply the adverse event rate for each of the 21 HACs for patients with one … event rates for the 21 MPSMS HACs using data from patients with all diagnoses, rather than being restricted … events for all diagnoses to adverse events for the four diagnoses.

147. Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/ade.pdf
     November 11, 2019 - Reducing Adverse Drug Events in Older Adults Reducing Adverse Drug Events in Older Adults 9-1 9. … National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … Adverse Drug Events in U.S. … National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … Drug Event/PC") OR (AB “Deprescription*” OR “Deprescribing” OR “Cessation” OR “Discontinuation”

148. Care for the Caregiver Program Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
     August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … event. … YES  NO       Adverse Event Investigation Process Is an adverse event policy in place … Do you have an event investigation process clearly outlined? … Providing supportive care following an unanticipated clinical event.

149. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - This paper will discuss FDA’s approach in developing the MedSun adverse event reporting program, including … The barrier to the movement of information within a facility is that an adverse event report made by … Step 3: Train the MedSun representatives to write complete and accurate adverse event reports. … A short video is being produced that depicts a device-related adverse event and demonstrates why it … Now they can be more proactive in addressing problems before they result in a serious adverse event.

150. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
     June 01, 2023 - event or mitigated its harm. 5 , 12 Although patient accounts do not always convey a complete picture … event or mediated its impact. 16 , 26 , 36 Perceived Promise of Reported Patient Experience for … event. 43  But these studies are largely limited to treatment-related errors. … a problem does not always result in a willingness or readiness to fully describe all aspects of the event … for patients to attribute responsibility for a problem, the less likely they are to report that the event

151. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO: Explain the diagram to others, and ask others to provide examples of adverse events that are not … event.

152. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
     September 01, 2013 - Safety and Adverse Events Previous Page   Table of Contents Universal ICU Decolonization … Safety and Adverse Events Chlorhexidine (CHG) Risk The risks associated with the use

153. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     June 02, 2025 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Management in this facility seems interested in patient safety only after an adverse event happens … No event reports  d. 6 to 10 event reports  b. 1 to 2 event reports  e. 11 to 20 event reports …  c. 3 to 5 event reports  f. 21 event reports or more SECTION H: Background Information This

154. Survey on Patient Safety (facility version) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     June 02, 2025 - Safety Instructions This survey asks for your opinions about patient safety issues, medical error, and event … · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Management in this facility seems interested in patient safety only after an adverse event happens … No event reports ( d. 6 to 10 event reports ( b. 1 to 2 event reports ( e. 11 to 20 event reports … ( c. 3 to 5 event reports ( f. 21 event reports or more SECTION H: Background Information This

155. Section 7C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
     June 02, 2025 - Table VII.C.1 – Distribution of insurance types and adverse … 58.2%) 0.10 <0.001 No Insurance 102 (3.2%) 0.04 0.001 Table VII.C.2 – Analysis of differences in adverse … event rates on insurance status, controlling for Chronic Condition Indicators and length of hospitalization

156. Table 7.A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
     June 02, 2025 - Table VII.A.1 – Distribution of race/ethnicity and adverse … Hispanic 352 (12.4%) 0.18 <0.001 Other 161 (5.7%) 0.12 0.12 Table VII.A.2 – Analysis of differences in adverse … event rates on race/ethnicity, controlling for Chronic Condition Indicators and length of hospitalization

157. Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
     March 01, 2020 - Reducing Adverse Drug Events in Older Adults Reducing Adverse Drug Events in Older Adults 9-1 9. … National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … Adverse Drug Events in U.S. … National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … Drug Event/PC") OR (AB “Deprescription*” OR “Deprescribing” OR “Cessation” OR “Discontinuation”

158. Final Progress Report: Improving the Safety of Primary Care by Measuring Adverse Events and Improvement (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/kennerly-report.pdf
     January 01, 2024 - event. … event, the conditions surrounding an adverse event, the conditions surrounding any treatment for the … adverse event, and the outcome of the treatment for each scenario. … event. … event along with any associated triggers.

159. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/adverse-drug-events.html
     August 01, 2018 - Adverse Drug Events Occurring in U.S. Hospitals Adverse Drug Events Occurring in U.S. … Hospitals (PDF, 1.5 MB) Source:   HCUP Statistical Brief #164: Characteristics of Adverse Drug Events

160. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. … While the vast majority of medication errors do not result in adverse patient outcomes, various studies … Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995;274(1):35–43. 3. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … MedWatch, the FDA safety information and adverse reporting program.