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81. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Introduction to Adverse Events Slide 23. Immediate Response to an Adverse Event 4 Slide 24. … Next Steps in Responding to an Adverse Event 5 Slide 25. … How to Communicate About an Adverse Event 6 Slide 26. … What if an Adverse Event Occurs on the Unit? … of emotions when an adverse event occurs.

82. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events? … Do staff have access to a system for reporting adverse events? … Is an attempt made to disclose within the first 24 hours following an adverse event? … Has an organized process to assess behavior related to the event been established? … Is supportive care provided to the caregiver within 24 hours of the event?

83. Dashboard Information | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/info.html
    June 01, 2019 - Dashboard Information NPSD Dashboards display data that follow the Common Formats for Event Reporting … – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions … There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific … modules for specific types of adverse events that are common. … Near miss: An event that did not reach a patient.

84. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events?         … Identification and Analysis of Actual and Potential Adverse Events Is there a process in place … Do staff have access to a system for reporting adverse events?         … Is an attempt made to disclose within the first 24 hours following an adverse event?         … Is supportive care provided to the caregiver within 24 hours of the event?        

85. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
    June 01, 2023 - But clarity of language does not necessarily help respondents determine whether an adverse event experienced … The Challenge: Most studies eliciting patient experience with medical errors focus on the adverse event … The focus of questions is on the immediate antecedents and outcomes of the adverse event. … event. … Exacerbated harms associated with the adverse event.

86. Pf-Engagement-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Discuss how to communicate an adverse event to patients and family members. … Slide 17 SAY: Each hospital has policies and procedures for actions to take after an adverse event … Immediately after an adverse event, care providers: Provide care. … Slide 19 SAY: Patients and family members experience a number of emotions when an adverse event occurs … Rarely does an adverse event occur as a result of intent.

87. Acute Care Learning From Defects
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
    November 01, 2019 - Events Adverse event: Patient develops acute kidney injury Learning from antibiotic-associated adverse … How will you reduce the risk of the adverse event from happening again? … Event Form a multidisciplinary team to develop potential solutions Seek input from a senior executive … event has been reduced 19 Changes in Antibiotic Decision Making AHRQ Safety Program for Improving … event and proposed changes to reduce the likelihood of the adverse event happening again?

88. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
    January 01, 2024 - Reviewers independently classified incidents, including whether a warfarin-related adverse event or … a potential warfarin-related adverse event was present, whether the event was preventable, and the severity … The adjusted incident rate ratio (IRR) for any preventable warfarin-related adverse event was 0.87 ( … 95% CI, 0.54, 1.4); for a serious preventable warfarin-related adverse event, the IRR was 0.50 (95% … event Potential warfarin- 82 101 0.79 0.77 (0.45, 1.3) related adverse event *Adjusted for nursing

89. Puh-Factraining-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
    June 02, 2025 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … It is more difficult for staff to identify which residents are at risk for a future adverse event or … These questions explore how the facility screens for risk of an adverse event (e.g., risk for delayed … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed.

90. Cusp Patient Family Engagement Facilitator Notes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
    June 02, 2025 - event Slide 21 SAY: Adverse events occur when a patient is harmed as a result of receiving medical … Slide 22 SAY: Each hospital has policies and procedures for actions to take after an adverse event … Immediately after an adverse event, care providers: · Provide care. … Slide 24 SAY: Patients and family members experience a number of emotions when an adverse event … Rarely does an adverse event occur as a result of intent.

91. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
    May 01, 2017 - Events An adverse event is an injury to a patient caused by medical intervention rather than by the … When an adverse event occurs, it can be difficult for a health care worker to take ownership and communicate … Prompt, compassionate, and honest communication with the patient and family after an adverse event is … in the medical record 18 AHRQ Safety Program for Perinatal Care Patient & Family Adverse Event … event experience their own trauma.

92. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
    December 01, 2014 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … It is more difficult for staff to identify which residents are at risk for a future adverse event. … Investigate root causes when an adverse event occurs. … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed.

93. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
    January 01, 2004 - In protocol A, the investigator reports this as an anticipated, nonserious adverse event that is not … Near-miss reporting systems have many potential benefits over adverse event detection systems. … “Near-miss” Reporting: Implications for Human Protection 189 Adverse event example. … to and management of the adverse event would have likely been less timely. … Web-based adverse event reporting will help notify the IRB of potential problems as they occur.

94. Chartbook on Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
    January 01, 2020 - OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect

95. Module 4: Teamwork and Communication | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
    March 01, 2017 - Events Adverse event: An injury to a resident caused by medical intervention rather than by the … When an adverse event occurs, it can be difficult for a care provider to take ownership and communicate … Prompt, compassionate, and honest communication with the resident and family after an adverse event is … Event Next Steps in Responding to an Adverse Event Care for the resident. … Slide 30: How To Communicate About An Adverse Event Speak slowly and use clear language.

96. Puh-Factraining-Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
    June 02, 2025 -  Nursing home staff generally do a good job of investigating and following up after an adverse event … It is more difficult for staff to identify which residents are at risk for a future adverse event … The questions in each Self-Assessment are tailored to the On-Time adverse event being addressed. … Discussion questions are tailored to the On-Time adverse event being addressed. … The menu includes meetings directly related to the adverse event of interest, but additional uses of

97. Data Measures Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur. … event occur Target Low adverse event rate Mobility NOT Intubated: Distribution of Adverse Events … event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur.

98. Engage Patients and Families for Perinatal Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
    May 01, 2017 - • Discuss how to communicate an adverse event to patients and family members. … Immediately after an adverse event, care providers: • Provide care. … event, and the care provided as a result of the event. … SAY: Patients and family members experience a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.

99. Innovations-Improve-Cr-Event-Summary (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/innovations-improve-cr-event-summary.pdf
    May 20, 2021 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … Matt’s program is that all patients who do CR virtually must have a caregiver present in case of an adverse … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 7 event during … Additional Details Event slides and a recording of the event provide additional details that complement … The event slides and recording are available online at: TAKEheart.ahrq.gov

100. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … not in all event categories, and 13 PSOs in all event categories). … Analytic Support for Adverse Events. … After first attempting to align their legacy adverse event reporting system with the AHRQ Common Formats … Notably, they require all members wishing to submit information on an adverse event to their PSO to