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381. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_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

382. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Although an individual clinician might be the proximal cause of an adverse event, organizational factors … occurred during the postoperative handoff communication process (mean 5.6; median 5.0 errors per handoff event … improve understanding of a patient’s current clinical status and expected trajectory, the verbal handoff event … Sentinel event statistics. Oakbrook Terrace, IL: The Joint Commission. … The nature of adverse events in hospitalized patients.

383. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize

384. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - ) is a traditional forum that provides clinicians with an opportunity to discuss medical error and adverse … Results: Twenty-one cases (12 medical, 9 surgical) representing adverse events were presented at the … Adverse events triggering case selection included unexpected deaths (six), unplanned intubations (two … In order to highlight specific systems issues that might have contributed to the adverse event, the … Adverse events triggering case selection are listed in Table 2.

385. Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
     December 01, 2014 - Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse … 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

386. A | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/a.html
     September 04, 2025 - Topics Browse A - Z A Access to Care Adverse Drug Events (ADE) Adverse Events

387. Pf-Engagement-Facnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-facnotes.docx
     May 01, 2017 - If an adverse outcome occurs, take the following immediate steps: 1. … Communicate with the patient – Providers communicate by sharing relevant facts about an adverse event … event. 4. … Document the event in the medical record – Providers must document in the medical record the facts of … event, and the care provided as a result of the event.

388. Table of Contents: Volume 1. Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     January 01, 2025 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November, … Voluntary Adverse Event Reporting in Rural Hospitals Charles P. Schade, Patricia Ruddick, David R. … Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy John R. … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … Mahoney Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from

389. Table of Contents: Volume 4. 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/TableofContents_Vol4.pdf
     January 01, 2025 - Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse … Voluntary Adverse Event Reporting in Rural Hospitals Charles P. Schade, Patricia Ruddick, David R. … Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy John R. … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … Mahoney Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from

390. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
     May 01, 2017 - cases of perinatal death or permanent disability reported to The Joint Commission under its sentinel event-reporting … 3 SAY: Further, EFM interpretation and management is a common issue in litigation involving adverse … Monitoring 8 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.

391. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - analysis, which are carried out after an adverse event occurs, failure modes and effects analysis ( … event actually occurs.3, 4 An FMEA does not focus on a specific event, but rather on a specific process … event, and 38.3 percent of these adverse events were due to medical error.16 It is estimated that each … Incidence of adverse events and negligence in hospitalized patients. … Sentinel Event Alert. Oakbrook Terrace, IL: Joint Commission.

392. Engage the Team and Applying CUSP in the ICU Setting Facilitator Guide
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
     April 01, 2022 - Safety Program for ICUs: Preventing CLABSI and CAUTI Applying CUSP ׀ 10 10 Where To Find Defects8,9 Adverse … event reporting systems Sentinel events Claims data Infection rates Process audits Staff safety assessments … Report template CAUTI Event Report template 5 Whys Staff Safety Assessment Brainstorming To generate … Event Report Tools The event report tools have the following domains: Demographics CLABSI/CAUTI information … ICU Video – Creating Team Buy-In To Work Toward Zero Preventable Infections in ICUs CLABSI and CAUTI Event

393. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - of SNFs and to examine the effects of the intervention on length of stay, cost, readmissions, and adverse … The primary outcome was 30-day readmissions. d) We also aimed to identify adverse outcomes potentially … any medical care discrepancies or concerns from the care teams were recorded as a transitional care event … and categorized by a geriatrician and hospitalist who reached consensus about whether a particular event … been submitted for publication: An interdisciplinary videoconference model for identifying potential adverse

394. Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
     January 01, 2024 - The group also collected data on adverse drug event rates and patient, staff, and physician satisfaction … Use Adverse Drug Event (ADE) trigger analysis research and the Hepler/Strand Pharmaceutical Care Model … Before implementation of this project, medication errors were the leading patient safety event within … However, all adverse drug event data, including errors detected related to medication reconciliation, … types was performed to determine the rate of change of adverse medication event diagnoses before and

395. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 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. 13 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.

396. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
     January 01, 2025 - We created a test plan and held a simulation event to evaluate proposed solutions and their integration … Call for Innovation Design Thinking Results - We conducted a design thinking event with stakeholder … coded as ‘1’ if a patient experienced at least one event pertaining to central line-associated blood … In contrast, susceptibility to an adverse ICU event appeared to be reduced by an increased number of … The machine learning analysis of the data predicted the likelihood of an adverse event with greater

397. Module 1 Implementation Guide: Welcome to the TAKEheart Initiative and an Overview of the Benefits of Increasing Cardiac Rehabilitation Participation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-implementation-guide.pdf
     January 01, 2018 - patients, hospitals/health systems and payersvi vii o CR reduces mortality over 1-3 years after a cardiac event … o CR reduces re- hospitalization and adverse events, such as subsequent MI o CR can help patients … multiple chronic conditions, diabetes, depression, mental stress and improves quality of life after an adverse … event • Payers are increasingly rewarding care that is better managed and that helps patients achieve … Ways to Reduce Barrier/Opposition Clinical manager -Improving patient health -Reducing adverse

398. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Were there adverse effects? What was the impact on quality of life? … Relationship between medication errors and adverse drug events. … Incidence of adverse events and negligence in hospitalized patients. … Computer adverse drug event (ADE) detection and alerts. … The clinical pharmacist’s role in preventing adverse drug events.

399. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - For example, hospitals that institute real-time adverse drug event surveillance systems are able to … Adverse drug event detection in pediatric oncology and hematology patients: Using medication triggers … Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals. … Adverse drug event trigger tool: A practical methodology for measuring medication related harm. … Automated adverse event detection collaborative: Electronic adverse event identification, classification

400. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - safety 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 … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that have implemented … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize