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21. Final Progress Report: Surveillance for Adverse Drug Events in Ambulatory Pediatrics (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bailey-kilbridge-report.pdf
    January 01, 2024 - The criteria for this rule had terms including “adverse drug event,” “adverse drug reaction,” “adverse … Pediatric Adverse Drug Event Surveillance with Natural Language Processing. … Results for Study Period Unique Signal Results for the Automated System Origin of Adverse Event … Results for Study Period Unique Signal Results for the Automated System Origin of Adverse Event … Results for Study Period Unique Signal Results for the Automated System Origin of Adverse Event

22. Mod4-System-Focused-Event-Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
    April 01, 2016 - When an adverse event occurs, too often, the focus is on an individual’s performance and is corrected … The sole objective of the event investigation and analysis of an adverse event or near miss is the … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Event review: the overall process of assessing an adverse safety event to determine contributing factors

23. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
    June 05, 2008 - event data. … Overview of Adverse Event Reporting The realization that medical adverse events are a leading negative … events in U.S. health care, adverse event reporting was largely ignored. … • The medical adverse event reporting system should be standardized across the State. … Patient safety and medical adverse event: A roadmap for state action. Portland, ME.

24. Final Progress Report: Partnering With Patients To Find Adverse Events (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/weingart2-report.pdf
    January 01, 2024 - The presence of any service quality deficiency more than doubled the odds of any adverse event or error … and to classify the type of event and its severity and preventability. … , for an adverse event rate of 8.7% [16]. … One event was serious. … The presence of any service quality deficiency more than doubled the odds of any adverse event, close

25. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix I Glossary Adverse safety event: a deviation … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Contributing factor: additional elements that contributed to the adverse event, many of which are outside … Event review: the overall process of assessing an adverse safety event to determine contributing factors

26. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
    January 01, 2003 - Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting 173 Development … of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting Andrew C. … ; and (2) whether these events can be classified as an adverse drug event (ADE), medication error (ME … ), medication error that leads to an adverse drug event (ADE/ME), or no event. … Description of a computerized adverse drug event monitor using a hospital information system.

27. CANDOR Event Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html
    August 01, 2022 - How to use this tool: Use the checklist to ensure that appropriate action is taken following an adverse … event. … : Hotline: Enter event report via the institution's event reporting system. … Report any adverse event to the appropriate professional responsible for patient safety events. … Enter all information in the hospital event reporting system.

28. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - Each focus group addressed one of the adverse event types, with all focus groups conducted using the … These correlations provide insight as to whether the adverse event type affected how patients and family … If adverse event affected the ranking of these common failures, then the correlations would be low.  … If adverse event type had no effect on ranking failure, these correlations would be high. … Table 9 provides insight as to whether the adverse event type affected how clinicians prioritized the

29. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - outcomes—to predict the expenditures attributable to the potentially preventable adverse medical event … We estimate that 20 percent ($6,998) of this difference was attributable to the actual adverse event … Patients who experienced a potentially preventable adverse medical event had 52 percent higher inpatient … However, any adverse event that was not preventable was likely due to a very severe chronic condition … Table 3 predicts the expenditures attributable to the potentially preventable adverse medical event

30. Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Hougland_26.pdf
    October 01, 2011 - Methods ICD-9-CM Adverse Event Classification The report “Adverse Events related to Medical Care … Adverse event-positive predictive value for ICD-9-CM codes N (%) Adverse event category All patients … for chairing the Expert Panel for Classification of Adverse Event ICD-9-CM Codes. … The ICD-9-CM adverse event classification. Available at: health.utah.gov/psi/icd9.htm. … Utah/Missouri Adverse Event ICD-9-CM Classification, final 2008 version.

31. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
    March 23, 2008 - Quality of care standards are especially salient when a trainee is faced with a patient adverse event … Yet, in adverse event situations in which care standards do not exist, rules with which to proceed are … The Institute of Medicine (IOM) definitions of medical error and adverse event were adapted for study … How many times have you not told a patient about an adverse event that affected them? 5. … Our study specifically studied the term “adverse event.”

32. Adverse Drug Events occurring in U.S. Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/adverse-drug-events.pdf
    June 02, 2025 - Adverse Drug Events occurring in U.S. … Hospitals 0 10 20 30 40 50 60 70 80 Adverse Drug Events Occurring in U.S. … Hospitals Adverse drug events (ADEs) are the most common nonsurgical adverse events that occur in hospitals … By hospital region Source: Statistical Brief #164: Characteristics of Adverse Drug Events Originating

33. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/index.html
    August 01, 2022 - In short, the CANDOR process is a more patient-centered approach that emphasized early disclosure of adverse … Reporting, Event Investigation and Analysis Event Reporting, Event Investigation, and Facilitator … Notes ( PowerPoint , 1 MB) Tool: CANDOR Event Checklist ( PDF , 200 KB) Tool: System-Focused Event … Event—Reasonable Care Video; Resolution Planning Video: Conversation with Family Adverse Event—Unreasonable … Care Video: Notification of Adverse Event Video: Planning for Meetings with Family Video: Disclosure

34. Grant Final Report: Toward an Optimal Patient Safety Information System (TOPSIS) (pdf file)
    www.ahrq.gov/sites/default/files/2024-04/koss-report.pdf
    January 01, 2024 - Perceived Value of Adverse Event Reporting. … Results Phase 1: Determining the Landscape of Adverse Event Reporting The Adverse Event Reporting … Use of Adverse Event Data. … Hospital Adverse Event Reporting Systems. … Use of Adverse Event Data.

35. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Module 4: Event Reporting, Event Investigation and Analysis AHRQ Communication and Optimal Resolution … of the event are imperative. … information on the event. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.

36. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … not admitting guilt, but rather admitting that an adverse event occurred while the patient was under … Making restitution—In the initial disclosure of the adverse event, caregivers need to be careful not … Potential future injuries that may result from the adverse event.

37. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - The objective of this initial conversation is to advise the patient and/or family that an adverse event … Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation.

38. 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 - The following definitions were used to code the type of event: • Adverse events were injuries that … 7 9 Definitely preventable 4 Probably preventable 3 Potential adverse event 38 46 Definitely … Use of morning report to enhance adverse event detection. … Event 2. … Event 3.

39. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - most hospitals across the country, many of the recommendations that come from root cause analyses of adverse … of an adverse event or near miss is the prevention of future adverse events. … When an adverse event occurs, too often, the focus is on an individual's performance and is corrected … other than the involved individual) that might have contributed to, facilitated, or even caused the adverse … The systems approach recognizes that all adverse events have multiple contributing factors, many of which

40. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
    May 01, 2003 - Physician Event Reporting: Training the Next Generation of Physicians 353 Physician Event Reporting … Each adverse event or near miss should be viewed and used as a learning experience to better understand … Discussion Traditional physician adverse event reporting behavior Physicians traditionally use a … administrators of possible litigation in the face of serious adverse events. … Reasons for not reporting adverse incidents: an empirical study.