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81. Mod01-Grand-Rounds-Slides (pdf file)
    ce.effectivehealthcare.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. … ■ Potential decrease in adverse events being litigated, which can potentially lead to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … Slide 16 6 – Facilitator Notes - Grand Rounds Presentation Say: A good response to adverse events … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events

82. Candor-Impguide (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
    April 01, 2016 - Recent research shows a significant correlation between the frequency of adverse events and malpractice … events and promote better care for patients through candid, caring communication in the wake of an adverse … – 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 … Determine a return on investment that ties to reduced adverse events. 14 – Implementation Guide for

83. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
    June 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … , with more than one-third of these adverse events deemed preventable. 63 These adverse events are associated … events in the ICU.65 However, few evidence-based approaches are available to structure written or verbal … event related to the ICU-ward handoff, and most of these adverse events were rooted in communication

84. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
    January 01, 2016 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers and falls … For example, measured adverse drug events continued to drop from 2014 to 2016, while measured pressure … Infections (CLABSI) Clostridium difficile Infections Falls Obstetric Adverse Events Pressure Ulcers … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS, including those in the Surgical … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number

85. Making Effective Changes in Antibiotic Decision Making (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
    November 01, 2019 - events in this case. … In this patient’s case, antibiotic-related adverse events caused harm but when thinking of potential … Events SAY: When evaluating factors that contributed to an actual or potential adverse event, … Events SAY: The five main categories that can contribute to antibiotic-associated adverse events … Slide 20 Summary In summary, adverse events related to antibiotics should be evaluated to determine

86. Clinical Pharmacists in Emergency Medicine (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
    February 21, 2008 - of these, or 3.8 million events, are thought to be preventable.9 Clearly, adverse drug events that … events in the ED is high.9 One analysis of adverse drug events reported to a national database showed … events of any other clinical environment, adverse drug events that occur in the ED are clearly a significant … The nature of adverse events in hospitalized patients. … The clinical pharmacist’s role in preventing adverse drug events.

87. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
    July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview Advancing Excellence … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … events. … view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse … events.

88. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
    July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Slide 17: Engaging After Adverse Events An adverse event is an injury to a patient caused by medical … events happen. … Organizations should be prepared to respond and communicate proactively when adverse events occur.

89. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
    June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated

90. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated

91. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
    January 01, 2004 - Introduction Various types of algorithms that identify complications of care and adverse events in … Rates of inpatient hospital adverse event reporting were calculated, where the total number of events … The validation sample used for this analysis was selected for inpatient adverse events which are reportable … Potential laceration or puncture adverse events associated with five principal procedures Events captured … Potential laceration or puncture adverse events associated with five principal procedures

92. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
    January 01, 2004 - (e.g., preventable adverse events, medical errors) among elderly Medicare fee-for- service (FFS) patients … men, while black patients are more likely to suffer surgery-related and nursing-related adverse events … These five adverse events are indicated with an asterisk in Table 5. … Table 4 further indicates that the probability of adverse patient safety events vary by gender, race … Licensed nurse staffing and adverse events in hospitals. Med Care 2003;41(1):142–52. 16.

93. PowerPoint Presentation
    ce.effectivehealthcare.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 … Potential decrease in adverse events being litigated, which can lead potentially led to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … events really hinges on knowing about them immediately.

94. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable … However, the role of language barriers and its impact on adverse events is less well documented. … The one hospital that stratified their adverse event data by language found clusters of adverse events … Common Causes of Adverse Events for LEP and Culturally Diverse Patients In addition to gathering the

95. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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 for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions?     … 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?        

96. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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? … Identification and Analysis of Actual and Potential Adverse Events: Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … 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?

97. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
    December 01, 2004 - Researchers have put forth many definitions of patient safety, errors, and adverse events. … It is important to note that not all errors will result in adverse events. … The importance of studying adverse events is obvious. Patients suffer when they occur. … The importance of studying the errors that precede the adverse events is also obvious. … Adverse drug events in high risk older outpatients. [See Comment.]

98. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2011-12.html
    January 01, 2018 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for special … Normalized to 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharges Adverse … 17,000 0.51 Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events

99. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
    July 01, 2022 - o How many and what type of adverse events occurred by specific vaccine brand. … This is important because if you are seeing increased adverse events related to a specific vaccine … This is important because if you are seeing increased adverse events related to a specific vaccine administrator … An additional pie chart (Figure 18) illustrates Resident or Staff Adverse Events by Manufacturer. … Figure 18 – Example Adverse Events pie chart Figure 17 - Example Vaccination Status To-Date pie chart

100. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - events—such as adverse drug events, falls, and pressure ulcers—occurred. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.