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181. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
     January 01, 2024 - A greater percentage of patients on control units experienced ≥1 adverse event post versus pre intervention … A similar percentage of intervention patients experienced ≥1 adverse event post versus pre intervention … This approach accounts for potential differences in the adverse event rates occurring on study units … The models used an interaction term and covariates identical to the adverse event models. … Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019. JAMA.

182. Behavioral Health AI Free Text Analysis - NPSD Data Spotlight (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/npsd-spotlight_behavioral-health.pdf
     September 01, 2025 - advice about discharge can have an increased risk of medical problems, including falls and other adverse … higher among medical inpatients than in the general population.2,3 Common BH-related issues or adverse … Adverse events occurring on mental health units. General Hospital Psychiatry. 2018. … Evidence-based interventions to reduce adverse events in hospitals: A systematic review of systematic … better understand the effect of BH issues on adverse events, patient and staff harm, patient safety

183. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4m_combo_psi18-19-obstetriclaceration-bestpractices.pdf
     May 20, 2016 - Patients and families may resort to legal action in order to offset the financial burden of an obstetric adverse … event.2 • Not only does obstetric trauma cause patient harm, it also significantly increases the cost … event prevention as an organizational priority and set performance goals for your hospital … Define and routinely monitor and analyze your hospital’s perinatal quality measure and obstetrical adverse … event rates against internal and external benchmarks

184. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     June 02, 2025 - 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

185. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
     January 01, 2024 - Specific Aim 2 Evaluate the impact of the EPh Program Hypothesis: The overall event (adverse drug event … • Adverse drug event (ADE) is defined as a preventable or nonpreventable “injury resulting from medical … • Potential adverse drug event (PADE) is defined as an incident that could have but didn’t cause injury …  Adverse drug event (ADE) is defined as a preventable or non-preventable “injury resulting from medical …  Potential adverse drug event (PADE) is defined as an incident that could have but didn’t cause injury

186. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/ref.html
     June 01, 2010 - Rosenthal J, Takach M. 2007 Guide to State adverse event reporting systems. … As used in this report, the term "serious reportable adverse health event" is defined as an event that … an undesirable outcome (death or serious harm) or significant potential for such an outcome, and the event … The term is used broadly to encompass the terms "critical incidents," "sentinel events," and "adverse

187. Exhibit 5.10. Experiential Training and Project Activities | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-10.html
     November 01, 2014 - Pareto, or "80/20," analysis is often used to reveal core sources of adverse outcomes. … followed by documentation of the current process ("current state map") with identification of points where adverse … Lesson learned: Documents insights and lessons learned from the event. … Report-out: Reports results from the event and any future process changes to be implemented as part of … Implementation: Implements the project widely within the department during the first 2 weeks after the event

188. Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
     January 01, 2024 - Overall adverse event (AE) occurrence and types of AE occurrence during the 30-day postoperative follow-up … event occurrence. … event Adverse event Training data Validation data Pulmonary complication 0.76 0.75 Congestive Heart … 1 The performance of the prediction model for the overall adverse event. … event.

189. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-results.html
     November 01, 2017 - event definition. … in hospitals, and the adverse event was obstetrical trauma only. 54 Further, this study found no increase … We used meta-analysis to estimate the overall incidence rate for maternal adverse event as 688 (95% CI … event (i.e., pneumonia) to a broader concept that includes additional potential pathophysiologic etiologies … addressed costs related to VTE leading to a pooled estimate of $17,367 additional costs for each VTE event

190. Medical Injury Identification Using Hospital Discharge Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
     January 01, 2003 - event occurrences. … event.5 All of the current national- and state- based systems described by Leape3 require some active … Not surprisingly, most of these systems have produced adverse event reports at rates substantially lower … event or medical injury rate / 100 discharges 3.7 16.6 2.9 13.3 % of Adverse event or medical … injury due to operations or procedures 48.0% 50.3% 44.9% 40.3% % of Adverse event or medical

191. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
     June 01, 2023 - Although the literature has established that patients can identify and reliably report on a range of adverse … substantial aftereffects can persist for many years, elicitation techniques must inquire about the impact of adverse … responsibility for eliciting accounts in ways compatible with how patients and families respond after an adverse … diagnostic event. … Identifying practices that affect the persistence of adverse effects long after a perceived diagnostic

192. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
     June 02, 2025 - Hospital management seems interested in patient safety only after an adverse event happens. … We are given feedback about changes put into place based on event reports. C3. … Number of Events Reported (No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1. … In the past 12 months, how many event reports have you filled out and submitted?

193. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
     July 01, 2018 - How to communicate an adverse event to patients and family members.

194. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     June 02, 2025 - · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Hospital management seems interested in patient safety only after an adverse event happens (1 (2 … 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

195. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
     July 01, 2020 - 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. … data are used, we follow these steps: • Multiply the adverse event rate for each of the 21 HACs for … MPSMS Adverse Event Associated With 41,639 1.40 40,500 1.36 42,398 1.43 48,518 1.63 Knee Joint

196. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
     June 02, 2025 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … When an event is reported, it feels like the person is being written up, not the problem ......... … Hospital management 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

197. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
     June 02, 2025 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … When an event is reported, it feels like the person is being written up, not the problem ......... … Hospital management 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

198. Development of a Comprehensive Medical Error Ontology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
     June 16, 2008 - • Capture the richness of the domain of errors and adverse events. … event. … MEDWATCH - The FDA Safety Information and Adverse Event Reporting Program. … misses and adverse events. … event+statistics.htm 10.

199. Evaluation Issues | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/issues.html
     August 01, 2022 - Others implemented patient safety interventions that plausibly might reduce the occurrence of adverse … AHRQ’s initial plan to require the PSML demonstration sites to collect Common Formats data on adverse … event reporting, for example, was ultimately not enforced by the Agency, in part because of the questionable … malpractice “claims tail” (i.e., that malpractice claims frequently take years from the occurrence of an adverse … event to surface and/or resolve).

200. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/intro.html
     August 01, 2022 - to establish an initiative to help States and health care systems test new models of care delivery, adverse … event disclosure, and dispute resolution, with the joint aims of (1) putting patient safety first by