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41. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/refs.html
    May 01, 2016 - Study of Adverse Events (ENEAS). … The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. … Incidence and types of adverse events and negligent care in Utah and Colorado. … Adverse events in British hospitals: preliminary retrospective record review. … What can hospitalized patients tell us about adverse events?

42. Building the Business Case for CANDOR Worksheet | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
    August 01, 2022 - Analyze the organization's frequency of adverse events and malpractice claims to support the rationale … Discuss efforts to improve communication and response to adverse events to date, including the clinical … event: Number of adverse events reported >24 hours after occurrence Severity level of adverse … (Track, analyze, and compare adverse events managed pre‑implementation, then follow up with additional … Determine a return on investment that ties to reduced adverse events.  

43. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - Results: The project generated new epidemiological evidence of patient safety risks and adverse events … The proposed Aims were: Aim 1: To analyze the frequency and determinants of errors and adverse events … Despite the frequency of ambulatory patient safety errors and adverse events, most efforts to study … Second, rare adverse events are challenging to accurately identify. … Adverse drug events in the outpatient setting: an 11-year national analysis.

44. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … Potential decrease in adverse events being litigated, which can potentially lead to lower malpractice … Slide 16 Say: A good response to adverse events really hinges on knowing about them immediately

45. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
    June 01, 2023 - Expanding the scope to also include “problems” encourages reporting of adverse events where patients … Given the uncertainties inherent in diagnosis, a portion of adverse diagnostic events that are not … The literature on medical errors documents that the long-term harms associated with adverse events are … diagnostic events. … First, when patients experience adverse medical events, they frequently switch to alternative venues

46. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
    August 24, 2015 - events. … When harm occurs, patients often express the desire to protect others from future events. … event. 11 Measuring Resolution Improvement Organizational performance, relative to adverse events Length … The severity level of adverse events reported. Length of time it takes to disclose the event. … These metrics include organizational performance relative to adverse events, financial impact, as well

47. I. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/intro1.html
    May 01, 2016 - Importantly, none of these events were documented in the hospital’s adverse event reporting systems. … Two-thirds of the adverse events were detected by patient interview alone, demonstrating that patients … could identify adverse events of which the hospital was unaware. … Weingart and colleagues 29 found that 73 percent of adverse events occurring in primary care practices … The collection of data was to focus on adverse events, near-miss events, and unsafe conditions as perceived

48. Patient and Family Engagement | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.html
    September 01, 2013 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Introduction to Adverse Events Slide 23. Immediate Response to an Adverse Event 4 Slide 24. … Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … events happen. … Organizations should be prepared to respond and communicate proactively when adverse events occur.

49. Declines in Hospital-Acquired Conditions (pdf file)
    ce.effectivehealthcare.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 … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections -37% … Falls -5% Obstetric Adverse Events -3% Pressure Ulcers Surgical Site Infections Ventilator

50. Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/wessell2-report.pdf
    January 01, 2024 - Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids … in Primary Care Final Progress Report Reducing Adverse Drug Events from Anticoagulants, Diabetes … STRUCTURED ABSTRACT Purpose and Scope: Reducing harm from adverse drug events (ADEs) is a national … Emergency Hospitalizations for Adverse Drug Events in Older Americans. … Trends in adverse events over time: why are we not improving? BMJ Quality & Safety.

51. Mod02-Business-Case-Worksheet (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/mod02-business-case-worksheet.pdf
    April 01, 2016 - – Analyze the organization’s frequency of adverse events and malpractice claims to support the rationale … – Discuss efforts to improve communication and response to adverse events to date, including the … event • Number of adverse events reported >24 hours after occurrence – Severity level of adverse … (Track, analyze, and compare adverse events managed pre implementation, then follow up with additional … Determine a return on investment that ties to reduced adverse events. 4 – Building the Business Case

52. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
    May 01, 2017 - Summary of impact on maternal and neonatal adverse events for L&D units submitting adverse event data … Impact on adverse events. … Events Absolute changes in adverse events from baseline to 10 months were measured using hospital … Because most of the adverse events monitored are rare, absolute changes in these events can result in … The measures used for adverse events were limited by the fact that most adverse events are rare, may

53. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
    June 04, 2008 - In particular, the exchange of device-related safety information and reports on adverse events with … Given that the FDA does not have unlimited resources to investigate and address adverse events with … adverse events and situations indicating the potential for harm related to these devices. … Obstacles to reporting adverse events to the FDA were identified as well. … KidNet’s focus is on identifying and reporting all medical device-related adverse events that occur

54. Acute Care Learning From Defects
    ce.effectivehealthcare.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 … events: What happened? … 10 Antibiotic-related adverse events are events that either caused harm or had the potential to cause … Events Five categories of factors that contribute to adverse events Patient factors are related to the … events related to antibiotics should be evaluated to determine areas for improvement.

55. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … December 2014 On-Time Overview 5 5 On-Time Reports Being Developed for Four Adverse Events Four Reports … for prevention discussion with On-Time reports How the facility investigates adverse events Talk to

56. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … On-Time Overview 5 October 2017 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … events.

57. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
    November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … November 2016 On-Time Overview 5 5 On-Time Reports for Four Adverse Events Available Reports: Pressure … Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events November

58. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
    July 01, 2020 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers/pressure … For example, measured adverse drug events continued to drop from 2014 to 2017, while measured pressure … Urinary Tract Infections Adverse Drug Events 99 92 88 86 https://www.ahrq.gov/sites/default/files … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … To estimate the rate of adverse events for each of the 21 HACs for all patients for which the MPSMS

59. Patient Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-ptsafety.html
    September 01, 2015 - from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.

60. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2013-refs.html
    October 01, 2015 - Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Obstetric Adverse Events Abuhamad A, Grobman WA. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.