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

62. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
    November 19, 2015 - About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated

63. Declines in Hospital Acquired Conditions (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
    June 04, 2018 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 8,000 deaths and saved $2.9 billion between 2014 … Adverse Drug Events CAUTI* *CAUTI - Catheter-Associated Urinary Tract Infections CLABSI+ Clostridium … difficile Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse … Events Pressure Ulcers Surgical Site Infections Ventilator- Associated Pneumonias 0% (Post-op

64. Executive Summary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
    June 01, 2023 - Although the literature has established that patients can identify and reliably report on a range of adverse … substantial aftereffects can persist for many years, elicitation techniques must inquire about the impact of adverse … events that occurred as much as 5 years in the past. … responsibility for eliciting accounts in ways compatible with how patients and families respond after an adverse … Identifying practices that affect the persistence of adverse effects long after a perceived diagnostic

65. Mod4-Event-Checklist (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
    April 01, 2016 - How to use this tool: Use the checklist to ensure that appropriate action is taken following an adverse … ■ Online: Review and prioritize events. … ■ Report any adverse event to the appropriate professional responsible for patient safety events. … ■ Collect medical records and other documents to establish timeline of events. … ; or Centers for Medicare & Medicaid Services “never” events

66. Patient and Family Engagement | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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. … Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Medical providers are committed to caring for their patients; however, adverse events can happen. … The Second Victim: Health Care Workers 7 Say: Adverse events are often system failures. … Organizations need to engage in strategies to address adverse events.

67. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
    June 01, 2023 - By contrast, the perceived mishaps patients and families report are more consistent with notions of adverse … Reporting: Reports from patients and families are vital complements to other methods of detecting adverse … identified five times as many errors and three times as many other adverse events as incident reports … A substantial body of literature addresses patient interactions with clinicians after adverse events, … repeated adverse events may be particularly reticent to report those experiences.

68. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … In many events, those not involved tend to believe that they could have predicted the event and therefore … Latent hazard: the hidden problems within health care systems that contribute to adverse events

69. Antibiotic Side Effects (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-side-effects.pdf
    June 01, 2021 - Antibiotic Side Effects Risk of antibiotic side effects and adverse reactions • Antibiotic use is … events are one of the most common reasons for emergency department (ED) visits for drug-related adverse … events • 1 in 1,000 antibiotic prescriptions leads to an ED visit for an adverse event. … Common side effects and adverse reactions • Gastrointestinal disturbances (such as diarrhea) occur … reactions Common side effects and adverse reactions Potential adverse reactions and drug-drug interactions

70. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
    June 01, 2023 - The missing evidence: a systematic review of patients’ experiences of adverse events in health care. … Can we rely on patients’ reports of adverse events? Med Care  2011;49(10):948-955. … Comparing patient-reported hospital adverse events with medical record review: do patients know something … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review … A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured

71. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
    January 01, 2024 - year in the US7; 5% experience potential adverse drug events,8 and 70% of these, or 3.8 million events … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review. … The nature of adverse events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients. … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review.

72. Appendix | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2013-appendix.html
    October 01, 2015 - 2013) 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 … in Measured HACs c Projected Cost Savings in 2013 d Projected Reductions in Deaths in 2013 e Adverse … $149,600,000 1,628 Falls 260,000 240,000 20,000 8% $144,680,000 1' 100 Obstetric Adverse … 50% 25% 10,000 $17,000 Falls 200,000 25% 50% 12.5% 25,000 $7,234 Obstetric Adverse

73. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
    July 01, 2023 - Although patient and family conceptions of adverse events do not always conform to clinical definitions … But patients and families do not describe adverse diagnostic events with such uniformity. … A substantial body of literature addresses patient interactions with clinicians after adverse events … repeated adverse events may be particularly reticent to report those experiences. … Can we rely on patients’ reports of adverse events?

74. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 17: Engaging After Adverse Events Say: Adverse events occur when a patient is harmed as a … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 22: The Second Victim: Health Care Workers Say: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … Organizations need to engage in strategies to address adverse events.

75. Cover slide
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
    May 01, 2013 - tools to improve communication among patients, families, and clinicians Discuss how to communicate an adverse … event Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … events happen When an adverse even occurs, it can be difficult for a health care worker to take ownership … when, where, and why) Document the event in the medical record Next Steps in Responding to an Adverse … events occur Tools Am I Ready To Become an Advisor?

76. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
    July 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 always … The literature on medical errors documents that the long-term harms associated with adverse events are … First, when patients experience adverse medical events, they frequently switch to alternative venues … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review

77. Project Overview: Designing Consumer Reporting Systems for Patient Safety Events | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
    October 01, 2014 - their family members are in a unique position to identify gaps in care that may have contributed to adverse … events. … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … events. … events.

78. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Slide 5 Say: Multiple studies have shown that involvement in medical errors and adverse events … It is estimated that one in seven patients is affected by adverse events, and that as many as half of … events and errors, and recognizes that not all adverse events are medical errors, and not all medical … errors are adverse events. … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

79. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/index.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 … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … events and a more proactive method to achieving an amicable and fair resolution for the patient/family … Care Video: Notification of Adverse Event Video: Planning for Meetings with Family Video: Disclosure

80. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - 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 … Preliminary 2017 2019 Goal (20% Reduction of each HAC) Adverse Drug Events 33.7 30.0 27.1 … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … Due to changes in how some conditions and adverse events are described in ICD-9 and ICD-10, the data