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341. Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-ptsafety.html
     September 01, 2015 - Ambulatory Medical Care Visits Due to Adverse Effects of Care Adult ambulatory medical care visits … due to adverse effects of medical care per 1,000 population, by sex, 2006-2007, 2008-2009 Source: … Importance: Adverse effects of medical care can arise from medical and surgical procedures as well as … from adverse drug reactions. … Ambulatory Medical Care Visits Due to Adverse Effects of Care Adult ambulatory medical care visits

342. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
     July 22, 2021 - IHS • Enhanced Adverse Event Reporting Capabilities: IHS Safety Tracking and Response (I-STAR) system … Future goal is to align the platform with AHRQ’s Common Formats for Event Reporting.

343. Arm in Arm with AcademyHealth, AHRQ is Poised to Build on Successes in Health Services Research | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/arm-in-arm-with-academyhealth.html
     June 01, 2024 - For example: AHRQ’s research supported efforts to significantly reduce in-hospital adverse events in … In a  JAMA article , researchers found that the relative risk of experiencing an adverse event diminished

344. Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
     July 01, 2023 - cases of perinatal death or permanent disability reported to The Joint Commission under its sentinel event-reporting … From Defects Say: A unit can decide its approach to debriefing events based on seriousness of event … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … event using an approach that does not shame or blame individuals. … Past adverse events related to EFM use.

345. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - Forty-five percent of the errors had adverse consequences. … event. … We were able to code 88 event narratives that met our usual criteria for a reportable event using the … Confronting an adverse medical event collaboratively helped both patients and providers with patients … Adverse events in primary care identified from a risk- management database.

346. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
     September 01, 2016 - One way to drive improved culture is to develop the norm of routine safety event reporting. … that encourage and facilitate patient safety Program Brief Network of Patient Safety Databases event … Watson Senior Vice President Michigan Health & Hospital Association 3 of adverse events and discussion … Several PSOs provide members a confidential analysis of patient safety event data, and provide forums … Exploring relationships between hospital patient safety culture and adverse events.

347. Harborview Medical Center Uses AHRQ’s Quality Indicators To Improve Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202504.html
     June 01, 2025 - A level 1 trauma center and safety net hospital, Harborview uses QIs to review adverse events and integrate … Using QIs has also improved Harborview’s Patient Safety and Adverse Events Composite rating ( PSI 90 … PSIs are a subset of QIs that focus on in-hospital safety issues, specifically for adverse events that

348. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - later found that 45.8 percent of ICU admissions (480 of 1,047 ICU admissions) were associated with an adverse … how and why the event occurred. … An alternative strategy for studying adverse events in medical care. … Sentinel Event Alert, Issue 25, February 26, 2002. … Surveillance of medical device-related hazards and adverse events in hospitalized patients.

349. E-Fetal-Monitoring Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
     May 01, 2017 - cases of perinatal death or permanent disability reported to The Joint Commission under its sentinel event-reporting … Slide 4 SAY: Further, EFM interpretation and management is a common issue in litigation involving adverse … Slide 12 SAY: A unit can decide its approach to debriefing events based on seriousness of event, expertise … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … event using an approach that does not shame or blame individuals.

350. Prologue: Technology and Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
     June 02, 2025 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … performance; and facilitate rapid access and dissemination of accurate medical information in the event … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … approaches have been proposed and tried over the years to improve medication management and minimize adverse

351. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - 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 … ; but for other event types, such as CLABSIs, only a fraction of patients are exposed to risk for the … event. … Sentinel Event Alert Issue 44; January 26, 2010.

352. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/preface.html
     May 01, 2016 - demonstrated the feasibility and promise of collecting information from health care professionals about adverse … data about concerns that patients have about the safety of their health care, including errors and adverse

353. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … Adverse Drug Events CAUTI* *CAUTI - Catheter-Associated Urinary Tract Infections CLABSI+ Clostridium … difficile Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse

354. Appendix: Incidence of Hospital-Acquired Conditions in the Partnership for Patients: Estimates and Projected and Measured Impact | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2014-ap1.html
     November 01, 2015 - 5,000 0.2 Falls MPSMS (2014) In-Hospital Patient Falls 260,000 7.9 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 74,000 2.3 MPSMS (2014) Adverse … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated … Goal for HAC Reduction f PfP HAC Reduction Goal g Estimated PfP Additional Cost* per HAC Adverse … 25% 10,000 $17,000 Falls 200,000 25% 50% 12.5% 25,000 $7,234 Obstetric Adverse

355. Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013-appendix.html
     October 01, 2015 - 9,200 0.28 Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 59,000 1.8 MPSMS (2013) Adverse … Events Associated With Hip Joint Replacements 21,000 0.63 MPSMS (2013) Adverse Events Associated … Measured HACs c Projected Cost Savings in 2013 d Projected Reductions in Deaths in 2013 e Adverse … Goal for HAC Reduction b PfP HAC Reduction Goal c Estimated PfP Additional Cost* per HAC Adverse

356. Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
     January 01, 2024 - not previously noted in preoperative evaluation or self-reported as pre-existing, were qualifying adverse … Any exacerbation of preoperative hearing changes was reported as an adverse event as well. … In addition, patients were screened for adverse events, including hearing loss and local or systemic … If either an infection or an adverse event of any kind was suspected per checklist criteria, the site … Similar statistical analyses were performed to assess secondary outcomes, safety outcomes, adverse events

357. Patient Imaging Quality and Safety Laboratory (PIQS Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html
     April 01, 2021 - The PIQs Lab assessed adverse event reports related to VIR over a 6-year period, finding that 45 percent … The most commonly reported adverse events were procedural complications (109; 29.1%), many of which had … Adverse events associated with peri-procedural handoffs, under review. 2020 Garry K, et al.

358. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - Key words: probabilistic risk assessment, adverse drug events, ambulatory setting 2 Purpose In our … For each fault tree, the investigator team calculated the overall percent time that each event occurred … by working down through the tree, multiplying each estimated frequency by the frequency of the event … We entered the calculated frequencies for each event on the trees and ran a series of analyses. … Quantitative Findings For each proximal errors, we began with the probability of the event with no interventions

359. Approaches to Address Health Risks for Older Adults
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
     March 15, 2025 - Opioids in Older Adults: Adverse Event Red Flags. https://www.ahrq.gov/sites/default/files/opioids_compendium … /2024-02/opioids-adverse-event-red-flags.pdf. … requiring 2 claims within 3 months of each other, with the 1st claim indicating the presence of an OUD event … Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare … Covariate┼ Assessment Window Follow-up Window Days(0, Censor * ) HRS-Medicare Cohort Time *OUD or OD event

360. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize