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161. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - Patient Safety Net (PSNet): "medical errors"[MeSH Terms] OR "iatrogenic disease"[MAJR] OR "sentinel event … systems approach"[All Fields] OR "medical error*"[All Fields] OR "medical mistake*"[All Fields] OR "adverse … event*"[All Fields] OR checklist ((medical error [mh] OR Diagnostic errors [mh] OR iatrogenic disease … [mh] OR sentinel surveillance [mh] OR safety [mh] OR (adverse [ti] AND (drug* [ti] OR event* [ti]))

162. Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/neonatal-interfacility-transfers-long-desc.html
     January 01, 2025 - The lab developed the Neonatal Transport Discrete Event Simulation (DES) model, encompassing communication … Human factors are the root cause of 67 percent of avoidable adverse events in transport due to communication … transport team, the MCP, and the receiving facility was associated with one-third of all identified adverse … Neonatal transport safety metrics and adverse event reporting: a systematic review . … Neonatal transport safety metrics and adverse event reporting: a systematic review .

163. Table 7B.1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
     June 02, 2025 - Table VII.B.1 – Distribution of numbers of Chronic Condition Indicators per patient and adverse … <0.001 3 or more body systems 125 (3.6%) 0.27 <0.001 Table VII.B.2 – Analysis of differences in adverse … event rates on Chronic Condition Indicators, controlling for length of hospitalization, based on GAPPS

164. II. Hotline Design and Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/design2.html
     May 01, 2016 - We also reviewed the minimum dimensions for adverse event reporting recommended by IOM and the AHRQ Common … Formats. g We examined instruments for collecting adverse events, errors, near misses, and unsafe … For example, focus group participants did not mention events with adverse or negative effects when they … event). … report with any internal source of information (e.g., adverse event report, patient complaint) and what

165. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/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

166. AHRQ-Funded Patient Safety Highlights: Improving Healthcare Safety by Supporting Measure Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
     August 01, 2025 - ■ Tools and Interventions: Created innovative adverse event-prevention tools and safety systems for … • They generally fell into two categories: those that directly receive adverse event reports and … support their analysis/investigation, and those that do not contain adverse event reports but may contribute … • Adverse event reporting by user facilities is relatively limited and is not well supported by existing … The medication safety initiative developed a NICU-focused trigger tool for adverse event detection,

167. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
     December 01, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form.

168. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
     January 01, 2016 - The use of these five sets of charts also eliminated the need to use 2005-2006 Medicare adverse event … Measures used to estimate the national HAC rate HAC Type Source Measure Adverse Drug Event MPSMS … Event Associated With Hip Joint Replacements MPSMS Adverse Event Associated With Knee Joint Replacements … event. … Event Associated With Hip Joint Replacements 48,993 1.65 MPSMS Adverse Event Associated With Knee Joint

169. Implementation of a Data-based Medical Event Reporting System 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/vol3/Davis.pdf
     February 12, 2004 - A system to track and trend near misses and adverse safety events for all the medical treatment facilities … MHSPSR is required to “review reports of adverse events, close calls, and root cause analyses; analyze … Patient Safety Registry (MHSPSR)”.1 The DoD Instruction authorized the registry to review reports of adverse … If there are no subcategories for an event, the number given to the event or the event description … This system is a useful tool in decreasing adverse safety events within the health care system.

170. Antibiotic Side Effects (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-side-effects.pdf
     June 01, 2021 - Antibiotic Side Effects Risk of antibiotic side effects and adverse reactions • Antibiotic use is … events are one of the most common reasons for emergency department (ED) visits for drug-related adverse … events • 1 in 1,000 antibiotic prescriptions leads to an ED visit for an adverse event. … Common side effects and adverse reactions • Gastrointestinal disturbances (such as diarrhea) occur … reactions Common side effects and adverse reactions Potential adverse reactions and drug-drug interactions

171. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
     March 01, 2017 - Slide 28: Communicating Adverse Events Say: Communication following an adverse event can been especially … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … Slide 30: How To Communicate About An Adverse Event Say: It is important to remember that residents … and family members can experience a number of emotions when an adverse event occurs, so communication … about an adverse event should be compassionate and sensitive.

172. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
     June 04, 2008 - event reports: • Ten device recalls and 39 other manufacturer actions (e.g., letters issued to … OIVD relies heavily for adverse event data on IVD devices on LISTSERVs™, literature reviews, manufacturer … LabNet’s second objective is to emphasize the importance of adverse event reporting to OIVD about both … event reporting that was simple and fairly quick (e.g., using forms that could be completed in less … event problems with diagnostic and therapeutic cardiac ablation, mapping, pacing, and defibrillation

173. Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/king-report.pdf
     January 01, 2024 - Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … (MODL-AF) Project Title: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … DOAC Warfarin Outcome and management model No. of patients with an event/ No. of patients (%) … % per year No. of patients with an event/ No. of patients (%) % per year IP-weighted Hazard … / No. of patients (%) % per yea r No. of patients with an event/ No. of patients (%) % per

174. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/neumiller.html
     August 01, 2017 - In the event of physician co-investigator review, the physician independently reviewed disputed cases … drug event; ED, emergency department. … Incidence and preventability of adverse drug events in nursing homes. … Incidence of adverse drug events and potential adverse drug events; implications for prevention: ADE … The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada.

175. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - care experience with patient safety events that may be useful and/or actionable in a patient safety event … system should collect information on all types of events, ranging from near-miss and no-harm events to adverse … to the event; whether or to whom the event was reported; what happened when the event was reported; … and the impacts or consequences of the event. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse

176. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - Event Any injury due to medical management. … Nonpreventable adverse event Unavoidable injury due to appropriate, error- free medical care Preventable … adverse event Injury due to a nonintercepted serious error in medical management Serious Medication … Reviewers categorized each incident as an adverse event, nonintercepted serious error, intercepted serious … Either can lead to increased error and adverse event rates.

177. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - event reporting system to include the reporting of medication errors. … MERP) criteria for categories G (resulting in permanent patient harm), H (resulting in a near-death event … event occurred. … Rare or unfamiliar circumstances compounded the potential that an adverse event would occur. … event, this would preclude the event from being reported in the NYPORTS database.6 Intervention carries

178. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - event” and “patient safety,” and a literature review with SCOPUS 1823, using the concepts “adverse … event,” “adverse reaction,” and “taxonomy.” … in the ED (36%) but is an uncommon POA event (6%). … An adverse event trigger tool in dentistry: a new methodology for measuring harm in the dental office … Performance of the adverse drug event trigger tool and the global trigger tool for identifying adverse

179. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
     January 01, 2004 - Data analysis The validation sample is based on the New York State inpatient adverse event report … Rates of inpatient hospital adverse event reporting were calculated, where the total number of events … New York State has several adverse event reporting systems, including the New York State Adult Cardiac … medical record reviews using a standard validation review instrument to determine if a reportable event … (present at admission or developed in the hospital), confirming the severity of the event (penetration

180. Final progress Report: Anticholinergics and Cognitive Decline in the Elderly with Depression (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/aparasu-report.pdf
     January 01, 2024 - : Using the previously validated Anticholinergic Drug Scale (ADS), the study evaluated the central adverse … The central adverse effects included dementia, cognitive impairment, hip/femur fracture, and all- cause … Evaluate other significant central adverse effects of clinically significant anticholinergics. … The problems of anticholinergic adverse effects in older patients. … The anticholinergic risk scale and anticholinergic adverse effects in older persons.