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61. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … analysis of an adverse event. … It explains that after an adverse event, regardless of whether it is due to human or system error, all … Discussions with patients/family after the initial communications about the adverse event Often take

62. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
    July 01, 2023 - Discuss how to communicate an adverse event to a patient and family members. … Engaging after an adverse event. Engaging in planning and design. … Slide 17: Engaging After Adverse Events An adverse event is an injury to a patient caused by medical … Slide 18: Immediate Response to an Adverse Event 4 Care for the patient. … Slide 21: Next Steps in Responding to an Adverse Event 6 Investigation.

63. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
    April 01, 2004 - events (the Vaccine Adverse Event Reporting System or VAERS) and automatic application of criteria … and future comparability with reports of the same adverse event in other studies. … Vaccine Adverse Event Reporting System. … Fever as an adverse event following immunization: case definition and guidelines of data collection … Hypotonic-hyporesponsive episode (HHE) as an adverse event following immunization: case definition

64. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
    March 01, 2004 - Methods ICD-9-CM codes suggestive of surgical adverse events An adverse event was considered to be … Codes selected as flags for surgery- related AEs numbered 377 and made up 23 adverse event classes (Appendix … To facilitate review, the chart abstraction tool contained the study definitions of adverse event and … The percentages for each adverse event Advances in Patient Safety: Vol. 1 250 class in the PVP … ICD-9-CM code-identified adverse events confirmed by medical record abstraction Adverse event class

65. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
    www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
    July 01, 2004 - Exposure/adverse event (the name of the exposure/adverse event). 2. … Adverse event (a list of adverse events to be examined for each measure). … The adverse event occurrence or the occurrence, of an event considered as a proxy for an adverse event … • the adverse event is common. … adverse event associated with the exposure

66. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
    July 01, 2004 - Exposure/adverse event (the name of the exposure/adverse event). 2. … Adverse event (a list of adverse events to be examined for each measure). … The adverse event occurrence or the occurrence, of an event considered as a proxy for an adverse event … • the adverse event is common. … adverse event associated with the exposure

67. Candor-Impguide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
    April 01, 2016 - event. … event … gathered and analyzed, and a plan is developed to prevent the adverse event from reoccurring … event (see Adverse Event [Reasonable Care] and Adverse Event [Unreasonable Care]). … event • Number of adverse events reported >24 hours after occurrence – Severity level of adverse

68. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2025 - Safety Review System (QSRS) Retrospectively Reviewing Inpatient Health Records To Identify Adverse … National Adverse Event Rates Available From QSRS This report reflects the evolution of combined efforts … Human abstractors answer questions to identify whether an adverse event occurred during a particular … Development of Adverse Event Monitoring Systems The Centers for Medicare & Medicaid Services (CMS) created … For almost 20 years, MPSMS was used to determine national rates for specific adverse events.

69. Patient Family Engagement PowerPoint Content and Alternate Text | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/patient-family-engagement/alt-text-tab.html
    September 01, 2013 - event to patients and family members Explore the role of patient and family as advisors … Event Occurs on the Unit?     … event   Slide 22 Introduction to Adverse Events Adverse event: An injury to a … event is essential   Slide 23 Immediate Response to an Adverse Event 3 Care for … in the medical record   Slide 24 Next Steps in Responding to an Adverse Event 5

70. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
    May 01, 2011 - the best care possible to patients, health care providers are sometimes faced with the aftermath of adverse … It is estimated that one in seven patients is affected by adverse events, and that as many as half of … all clinicians will be involved in a serious adverse event at least once during their career.   … adverse events. … Ensure adverse event report completed. Manage unit/team’s overall response.

71. Table 5.A.1. Evidence Table (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - Adverse Drug Event Detection in Pediatric Oncology and Hematology Patients: Using Medication … Recognizing hypoglycemia in children through automated adverse-event detection. … Adverse drug event trigger tool: a practical methodology for measuring medication related harm … Automated adverse event detection collaborative: electronic adverse event identification, classification … Adverse Inspector adverse event (AE) detection methods in a Events in Hospitals: General Report population

72. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
    July 01, 2022 - Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose. … Adverse Event (Reaction) to any COVID-19 Vaccine Dose? … Select Adverse Event (Reaction) to 1st Dose. … Select Adverse Event (Reaction) to 2nd Dose.

73. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
    July 01, 2022 - Researchers found significant decreases in in-hospital adverse event rates for heart attack, heart failure … Researchers of this study tracked a total of 21 adverse events over the study period. … Tracking the rates of adverse events is a common way of measuring changes in patient safety. … In the observed data for 2010 and 2019, adverse event rates fell 36 percent for heart attack patients … After adjustment, the relative risk of experiencing an adverse event diminished for all five patient

74. Final Progress Report: Risk and Recovery in Complex Environments: Labor and Delivery as a Model (pdf file)
    www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
    January 01, 2025 - Despite efforts to provide safe, effective care, adverse events still occur. …  What makes a case most vulnerable to adverse events? … modes, failure detection, and management of adverse event sequelae relevant to our clinical focus were … [3] Pivotal event – A pivotal event is an intermediate event for which occurrence or non- occurrence … of the event

75. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Reporting, Event Investigation and Analysis Analysis Module 5: Response and Disclosure Module 6: … Generally, the CANDOR process begins with identification of an event that involves harm. … institutions include how to: Engage patients and families in disclosure communication following adverse … Implement a Care for the Caregiver program for providers involved in adverse events. … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

76. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
    January 01, 2024 - We defined a preventable adverse event as an adverse event associated with an error. … If the ED patient was admitted and screened positive for a possible adverse event, chart abstractors … In cases when a critical error was responsible for a preventable adverse event, the data point was … entered into the analysis only as a preventable adverse event to prevent double counting. … We tried to address this by including a return to the ED within 48 hours as a potential adverse event

77. Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/dierks-report.pdf
    January 01, 2024 - Simply because the system has not realized a catastrophic adverse event does not mean that it is ‘ … Time pressures can increase with each instance of an adverse event, particularly if it occurs in … ‘Successful’ waiving (i.e., waiving without incurring an adverse event) reduces time pressure, whereas … ‘unsuccessful’ waiving (i.e., waiving with a subsequent adverse event) increases time pressure. … Exposure leads to a transition to one of two outcomes: 1) adverse event/harm or 2) no adverse event

78. I. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/intro1.html
    May 01, 2016 - Most adverse event reporting systems (with a few exceptions) are designed to be used by health care providers … Importantly, none of these events were documented in the hospital’s adverse event reporting systems. … event detected by interview, and 11 percent had at least one adverse event identified by medical record … Similarly, Weingart and colleagues, studying adverse event reports from ambulatory oncology patients, … Program (MERP); the Food and Drug Administration Safety Information and Adverse Event Reporting Program

79. Cover slide
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
    May 01, 2013 - event to a patient and family members Learning Objectives The Patient’s Hospital Experience1 Clinicians … Event Occurs on the Unit? … event Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … event is essential Immediate Response to an Adverse Event4 Care for the patient Report to the appropriate … parties Communicate with the patient (who, what, when, where, and why) Document the event in the medical

80. VI. Summary and Conclusions | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
    May 01, 2016 - event reporting systems). … event reporting by health care professionals. … When adverse event reporting systems were first built, they did not receive many reports.  … It was not until the culture in hospitals changed around adverse event reporting that reports started … Depending on whether the information is used to supplement an existing adverse event report or is a new