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361. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.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

362. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
     March 31, 2008 - , provider, or practice because the attributes of that event were so unusual. … Multiple roles could be involved in any single error event. … Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556-1564. 7. … Adverse events in primary care identified from a risk- management database. … Mixed methods analysis of medical error event reports: a report from the ASIPS Collaborative.

363. Chapter 4. Results and Key Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter4.html
     August 01, 2022 - What caused the patient safety event to happen? Where did the patient safety event happen? … systems 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 an event was reported; what happened when an 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

364. Final Progress Report: Improving the safety of pediatric tracheal intubation in ICUs with apneic oxygenation and video laryngoscopes (pdf file)
     www.ahrq.gov/sites/default/files/2025-06/nishisaki3-report.pdf
     January 01, 2025 - The purpose of this project was to decrease adverse TIAEs in critically ill children by implementing … These pediatric-specific features increase risks and adverse events associated with TI procedures. … We also identified that oxygen desaturation is closely associated with adverse TIAEs. … Primary video laryngoscope use was significantly associated with lower adverse TIAEs. … Primary video laryngoscope use was significantly associated with lower adverse TIAE rates.

365. Comparing Quality Scores to an Independent Standard | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
     January 01, 2023 - standard that is beginning to emerge in health care: the standard of “never” or zero percent for certain adverse … While “zero-tolerance” is implied by the term “never event,” this may not be language that the public

366. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
     November 01, 2017 - Drug Events (ADE) An event in which administration of a medication results in harm to a patient. … event definition. … We used meta-analysis to estimate the overall incidence rate for maternal adverse event as 688 (95% … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[

367. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
     November 01, 2017 - Drug Events (ADE) An event in which administration of a medication results in harm to a patient. … event definition. … We used meta-analysis to estimate the overall incidence rate for maternal adverse event as 688 (95% … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[

368. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Thromboembolism 0 414 Medication Safety 126 416  -- Medication Errors/Preventable Adverse … Ordering/Prescribing Errors 6 418  ---- Transcription Errors 5 415  -- Side Effects/Adverse … Robotic-Assisted Surgery 0 665  ---- Computer-Assisted Radiotherapy 0 661  -- Computerized Adverse … Event Detection 6 667  -- Telemedicine 0 691 Driving Change 56 692 Risk

369. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-040913.ppt
     June 02, 2025 - Infrastructure advisory Engaging in everyday care How-to strategies Engaging with after an adverse … event * Hopkins Model for Leading Change * The 4 Es Senior Leaders Team Leaders Frontline Staff … on the CUSP team Provide input to improve policies and procedures Advise on how to communicate an adverse … event to a patient and family members Present at staff meetings “stories of care” * Teams Make

370. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
     February 21, 2008 - Incidence and types of adverse events and negligent care in Utah and Colorado. … The nature of adverse events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients. … Systems analysis of adverse drug events. ADE Prevention Study Group. … The clinical pharmacist’s role in preventing adverse drug events.

371. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
     January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections … -37% Falls -5% Obstetric Adverse Events -5% Pressure Ulcers 6% Surgical Site

372. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
     January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections -37% … Falls -5% Obstetric Adverse Events -3% Pressure Ulcers Surgical Site Infections Ventilator

373. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize

374. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
     November 19, 2015 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize

375. V. Challenges Identified and Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/lessons5.html
     May 01, 2016 - the language health care professionals have come to accept as the standard—including such terms as “adverse … an 8 th grade (or lower) reading level in all materials aimed at potential respondents: the patient event … surveys and complaint departments) and information about patient safety concerns from staff (e.g., adverse … event reporting systems). … The physicians who classified the patient event reports according to event type, harm, duration of harm

376. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
     May 20, 2016 - multidisciplinary review is required to identify system processes that may result in failures in care, adverse … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … • Find ways to prevent recurrence of the event if preventable. … • Recommendations are made to prevent recurrence of a similar event.

377. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
     August 01, 2022 - The TEP includes experts in patient safety, patient safety event reporting systems, health care delivery … systems 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 an event was reported; what happened when an 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

378. Information to Help Hospitals Get Started (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pdf
     June 02, 2025 - Research shows patient-centered communication can improve: – Patient safety • More than 70% of adverse … • Nearly 20% of patients experience an adverse event within a month of discharge, of which ¾ could be … prevented • Common complications post-discharge are adverse drug events, healthcare-associated infections

379. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - Initially, errors are detected by hospital staff who complete Event Registration and Event Discovery … , they then asked staff to report any pain medication-related activities that did not result in an adverse … Additional methods include a telephone hotline for the reporting of adverse drug events and retrospective … review of the clinical record for documentation of evidence of an adverse event.” … the collective understanding of the event

380. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - regarding the definition of true postoperative respiratory failure, it still remains an important patient adverse … event. … at increased risk for postoperative respiratory failure to better prepare clinicians to anticipate adverse … Decreased central nervous system input (head injury, ingestion of central nervous system depressant, adverse … Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality