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281. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2013.html
     November 01, 2015 - MPSMS data provide inpatient mortality data for the patients who experienced each type of adverse event … , and for patients who were exposed to risk for the event. 14 These MPSMS mortality data were of interest … For pressure ulcers and falls, 100 percent of patients are exposed to risk for the event; but for other … event types, such as CLABSIs, only a fraction of patients are exposed to risk for the event. … patients who received a central line as part of their inpatient care are considered at risk for the event

282. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - Adverse event reports of falls and medication errors were analyzed to evaluate the value of tools for … Key Words: patient safety, medical errors, reporting, adverse events, disclosure 3 Overall Purpose … Anticoagulation Monitor Methods: The Anticoagulation Monitor was developed to reduce adverse drug events … Language Processing Methods: Test the potential of Natural Language Processing technology to detect adverse … Reporting of adverse drug events: Examination of a hospital incident reporting system.

283. Hospital Survey on Patient Safety Culture Version 2.0 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
     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 … resulting from the processes of healthcare delivery. · A “patient safety event” is defined as any type … When an event is reported in this unit, 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 1 2 3

284. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ref.html
     December 01, 2014 - Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Adverse drug events in U.S. hospitals, 2004. HCUP Statistical Brief #29. … Impact of a comprehensive strategy on obstetric adverse events. … Sentinel Event Alert Issue 44; January 26, 2010.

285. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013-refs.html
     October 01, 2015 - Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Obstetric Adverse Events Abuhamad A, Grobman WA. … Impact of a comprehensive strategy on obstetric adverse events. … Sentinel Event Alert Issue 44; January 26, 2010.

286. Mod5-Case-Scenarios (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
     April 01, 2016 - ........................................................2 Scenario 2: Disclosure Immediately After Event … ....................................................................3 Scenario 3: Disclosure After Event … ....................................................................4 Scenario 4: Disclosure After Event … and surgeon, along with a lack of familiarity with the new equipment as an important cause of the adverse … event.

287. Final Progress Report: Detecting, Assessing, and Learning from Patient-Perceived Breakdowns in Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/mazor-report.pdf
     January 01, 2024 - workers.(6) Such reporting allows healthcare systems to respond to a specific adverse event or error … and to determine how the event occurred to prevent recurrences.(7) However, adverse event reporting … This growing emphasis on adverse event reporting has occurred alongside an understanding that patients … in their care that were not detected by the institutional adverse event reporting systems or by chart … Some patients may be mistaken and believe an adverse event happened when in fact that was not the case

288. Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ulep.pdf
     January 01, 2004 - is synonymous with the terms incident, adverse event, and error. … system that limits the amount and type of adverse event information that can be gathered and analyzed … the event form to match the type of event being reported. … the event? … Developing a comprehensive electronic adverse event reporting system in an academic health center.

289. Gap Analysis Facilitator's Guide: Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
     August 01, 2022 - management of patient safety events by implementing processes that facilitate full disclosure of an adverse … event, apology, and fair and rapid resolution.

290. Section 5, Tables (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-5-tables.pdf
     January 01, 2007 - units 0.87 dysfunctional organs Nosocomial infections 65 (20%) 79 (25%) 0.16 At least 1 adverse … event 97 (30%) 90 (28%) 0.59 Mechanical ventilation 6.2 ± 5.9 days 6.0 ± 5.4 days 0.76

291. Patient and Family Engagement in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
     May 01, 2017 - Communicate with the patient – Providers communicate by sharing relevant facts about an adverse event … event. … event, and the care provided as a result of the event. … PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events).

292. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
     November 30, 2010 - Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse … A cohort study of Medicare enrollees in the ambulatory clinic setting demonstrated an adverse drug event … The study flow process, including a description of visit event content and temporal relationships, is … drug events Adverse drug event self-reporting script Naranjo algorithma GLMMd Hospital admissions … A method for estimating the probability of adverse drug reactions.

293. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2011-12.html
     January 01, 2018 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for special … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharges Adverse … Drug Event (ADE) MPSMS ADE Associated With Digoxin 9,400 0.29 11,000 0.32 MPSMS … Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse

294. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-intro.html
     August 01, 2024 - The health system uses an anonymous incident reporting system, enabling employees to report potential adverse … 8 years, a specialized team made up of nurses, doctors, and medical specialists has analyzed these adverse … the Root Cause Analysis and Action (RCA2) methodology. 1 An analysis of 276 severe and catastrophic adverse

295. Strategy 4: IDEA Discharge Planning (Tool 3) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
     January 01, 2010 - for engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … event within 30 days of discharge. … three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … The incidence and severity of adverse events affecting patients after discharge from the hospital.

296. National Healthcare Quality And Disparities Report Patient Safety Chartbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - • Hospital patients with an anticoagulant-related adverse drug event due to low-molecular- weight … drug event to warfarin (Adverse drug events) … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … • The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are: …  Percentage of hospitalized adult patients who had an adverse drug event related to warfarin use

297. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
     January 01, 2024 - Second, rare adverse events are challenging to accurately identify. … event. … These surprising results suggested that the adverse event rate from antimicrobial prophylaxis was far … Food and Drug Administration Adverse Event Reporting System (FAERS). … Adverse drug events in the outpatient setting: an 11-year national analysis.

298. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
     January 01, 2017 - can redesign care and delivery processes to improve care and minimize the occurrence of errors and adverse … checklists, and create independent checks for key processes, we improve our ability to reduce the risks of adverse … Adverse event reporting systems are common in hospitals. … Slide 16 Staff Safety Assessment SAY: Adverse reporting systems, sentinel events, and claims data … are reactive—the unfortunate event has already occurred.

299. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
     August 01, 2023 - (negatively worded) • More about this item: When an event is reported, it feels like the person is … In this unit, we are informed about changes that are made based on event reports. … Hospital management seems interested in patient safety only after an adverse event happens. … item: Hospital managers are only interested in doing something about patient safety when there is an adverse … event or a patient is harmed. 10.

300. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
     January 01, 2021 - 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 … • A “patient safety event” is defined as any type of healthcare-related error, mistake, or incident … In this unit, we are informed about changes that are made based on event reports ........... … Hospital management seems interested in patient safety only after an adverse event happens .......