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261. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
     June 02, 2025 - and thus have accrued more costs even prior to the adverse event. … Therefore, choose a group that did not experience the adverse event that is as comparable as possible … both costs and risk of the adverse event (e.g., concurrent cancer diagnosis). … Ideally, if your data permit, consider only costs that occur after the adverse event occurred. … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866199/psn-pdf
     June 26, 2024 - The role of pediatric nurses during preventable adverse event disclosure: a scoping review. … The role of pediatric nurses during preventable adverse event disclosure: a scoping review. … https://psnet.ahrq.gov/issue/role-pediatric-nurses-during-preventable-adverse-event-disclosure-scoping … https://psnet.ahrq.gov/issue/role-pediatric-nurses-during-preventable-adverse-event-disclosure-scoping-review … https://psnet.ahrq.gov/issue/role-pediatric-nurses-during-preventable-adverse-event-disclosure-scoping-review

263. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33588/psn-pdf
     March 15, 2025 - all clinicians will be involved in a serious adverse event at least once during their career. … when a clinician is involved in any error or adverse event, regardless of severity. … event. … by the event." … Providing Support to Clinicians After an Error or Adverse Event A survey of 898 clinicians at the University

264. Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database. | PSNet
     psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents-nations-largest-event
     July 24, 2024 - safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event … Safety Trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event … January 16, 2025 Adverse Health Events in Minnesota: Annual Reports. … March 20, 2024 Adverse Events. … November 8, 2023 Indian Health Service: Actions Needed to Improve Use of Data on Adverse

265. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50596/psn-pdf
     October 30, 2019 - Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines … Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines … https://psnet.ahrq.gov/issue/encouraging-resident-adverse-event-reporting-qualitative-study-suggestions … - front-lines Encouraging adverse event reporting among health care providers, including medical trainees … https://psnet.ahrq.gov/issue/encouraging-resident-adverse-event-reporting-qualitative-study-suggestions-front-lines

266. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - event. … and analyzed, and a plan is developed to prevent the adverse event from reoccurring. … event. … event. … event (see Adverse Event (Reasonable Care) and Adverse Event (Unreasonable Care)) .

267. Mod5-Disclosure-Checklist (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
     April 01, 2016 - is identified, advise the patient and/or family that an adverse event may have occurred … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize ■ Say you are sorry for the adverse event in a sincere manner early in the conversation.

268. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.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. … Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … Next Steps in Responding to an Adverse Event 5 Investigation.

269. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42822/psn-pdf
     December 18, 2013 - Automated adverse event detection collaborative: electronic adverse event identification, classification … Automated adverse event detection collaborative: electronic adverse event identification, classification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification

270. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837764/psn-pdf
     August 03, 2022 - Disparities in adverse event reporting for hospitalized children. … Disparities in adverse event reporting for hospitalized children. … https://psnet.ahrq.gov/issue/disparities-adverse-event-reporting-hospitalized-children Voluntary event … https://psnet.ahrq.gov/issue/disparities-adverse-event-reporting-hospitalized-children https://psnet.ahrq.gov … /primer/reporting-patient-safety-events https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reported-state-adverse-event-reporting-systems

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60669/psn-pdf
     July 08, 2020 - Participation in a system-thinking simulation experience changes adverse event reporting. … Participation in a system-thinking simulation experience changes adverse event reporting. … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event … - reporting This study found that improvements in systems thinking increase adverse event (AE) reporting … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting

272. Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data. | PSNet
     psnet.ahrq.gov/issue/implementation-evaluation-and-recommendations-extension-ahrq-common-formats-capture-patient
     June 13, 2018 - The authors propose adjustments to AHRQ's Common Formats for safety event reporting that allow patients … and caregivers to more effectively report adverse events. … An Annual Perspective emphasized the value of patient adverse event reporting in larger efforts to … event reporting: a qualitative study of suggestions from the front lines. … July 25, 2018 Families as partners in hospital error and adverse event surveillance.

273. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 02, 2025 - • Appropriate comparator: When trying to identify the cost attributable to an adverse event captured … and thus have accrued more costs even prior to the adverse event. … Therefore, choose a group that did not experience the adverse event that is as comparable as possible … Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost

274. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - ■ 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 … Resolution should lead to a settlement of issues related to the adverse event, but doesn’t always lead … Slide 38 Say: The concept of accountability relates to what patients want, following an adverse event

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47265/psn-pdf
     February 22, 2019 - Introduction of a mobile adverse event reporting system is associated with participation in adverse … Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse … - adverse-event Physicians historically are low utilizers of voluntary error reporting systems. … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event

276. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     July 01, 2023 - Discuss how to communicate an adverse event to patients and family members. … Engaging after an adverse event. Engaging in planning and design. … Immediately after an adverse event, care providers: Provide care. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.

277. National trends in patient safety for four common conditions, 2005–2011. | PSNet
     psnet.ahrq.gov/issue/national-trends-patient-safety-four-common-conditions-2005-2011
     August 03, 2016 - event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive … The results show a significant decline in adverse event rates for acute myocardial infarction and congestive … June 22, 2022 Trends in adverse event rates in hospitalized patients, 2010-2019. … April 5, 2016 Hospital COVID-19 burden and adverse event rates. … November 27, 2013 Few Adverse Events in Hospitals Were Reported to State Adverse Event

278. National Web-Based Teleconference on Health IT and Safety - Using Health IT to Prevent Adverse Events (pdf file)
     digital.ahrq.gov/sites/default/files/docs/Health_IT_and_Safety_070910_comp.pdf
     July 13, 2010 - ) on adverse drug events using a clinical event monitor • Hinrichsen (JAMIA 2007) on vaccine adverse … Self reporting in the EHR • Accident • Active Error • Adverse • Adverse Drug Event • Adverse Drug … Reaction • Adverse Event • Adverse Medical Event • Adverse Outcome • Allergic Reaction • Bad … outcome 41% Without adverse outcome 58% Near miss with recovery 1% Large scale event reporting … events Event reporting Event reporting (cont'd.)

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837139/psn-pdf
     May 18, 2022 - Multispecialty physician online survey reveals that burnout related to adverse event involvement may … Multispecialty physician online survey reveals that burnout related to adverse event involvement may … https://psnet.ahrq.gov/issue/multispecialty-physician-online-survey-reveals-burnout-related-adverse-event … https://psnet.ahrq.gov/issue/multispecialty-physician-online-survey-reveals-burnout-related-adverse-event-involvement-may … https://psnet.ahrq.gov/issue/multispecialty-physician-online-survey-reveals-burnout-related-adverse-event-involvement-may

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73588/psn-pdf
     August 11, 2021 - Reporting of death in US Food and Drug Administration medical device adverse event reports in categories … Reporting of death in US Food and Drug Administration medical device adverse event reports in categories … Based on medical device adverse event data reported to the FDA's Manufacturer and User Facility Device … https://psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports … https://psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports