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21. Declines in Hospital-Acquired Conditions (pdf file)
    pcmh.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

22. Patient and Family Engagement | Agency for Healthcare Research and Quality
    pcmh.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.

23. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
    March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … events were occurring in order to prevent them. … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features The QSRS: Offers an expanded array of adverse event measures. … Provides additional detail for the most frequently occurring events.

24. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    pcmh.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

25. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    pcmh.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?        

26. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    pcmh.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

27. AHRQ Views Blog: At the American Society of Health Economists Conference, AHRQ Highlights Its Deep Dive Into COVID-19 | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/news/newsletters/e-newsletter/868.html
    June 01, 2023 - Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Did Not Adverse tracheal intubation-associated events—unwanted events that occur as a result of the … tracheal intubation-associated events. … events.

28. Mod4-Event-Checklist (pdf file)
    pcmh.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

29. Improving Patient Safety Systems for Limited English Proficiency Patients
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pptx
    January 01, 2011 - patients Provide evidence for why we should focus on LEP patient safety Identify common causes of adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Nearly 25 million people in the United States (8.6%) are defined as LEP and therefore at risk for adverse … competence, and patient-centered care as important elements of safe quality of care Causes of Adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study.

30. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
    December 01, 2012 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: Systems … Identify common causes of adverse events for LEP and culturally diverse patients. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Return to Contents Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Use … Language proficiency and adverse events in U.S. hospitals: a pilot study.

31. Analyzing Big Datasets to Improve Healthcare Quality, Equity | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-hernandez-boussard.html
    April 01, 2024 - her career to analyzing “clinical big data” to identify quality and safety issues that can result in adverse … events. … ), she profiled adverse events for various surgical events such as heart bypass surgery, breast reconstruction … Hernandez-Boussard also examined factors that could contribute to adverse events such as hospital surgical … Her research focuses on older patients and aims to mitigate the risk of adverse outcomes related to postoperative

32. AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/research/findings/making-healthcare-safer/index.html
    July 01, 2023 - Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse … events and associated systemic and contextual factors.

33. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - (PDF, 11.1 MB) Text Description: 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 … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease. … Obstetric events: 3% decrease. Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

34. Mod01-Grand-Rounds-Slides (pdf file)
    pcmh.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

35. About the Toolkit Development | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
    July 01, 2023 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Background Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse … and 70 percent of sentinel neonatal events. … inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk of adverse … events on L&D units.

36. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    pcmh.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

37. Improving Patient Safety Systems for Limited English Proficiency Patients: A Guide for Hospitals (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
    January 01, 2011 - 10 20 30 40 50 Pe rc en t Type of Physical Harm Types of Physical Harm Experienced From Adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … http://teamstepps.ahrq.gov/� http://teamstepps.ahrq.gov/� Summary  Adverse events that affect LEP … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Causes of Adverse Events for LEP and Culturally Diverse Patients Systems and Strategies To Improve Safety

38. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    pcmh.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

39. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/resources/improve-discharge/index.html
    July 01, 2022 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Events After Discharge Transitions of Care Project BOOST (Better Outcomes for Older Adults through … Events With AHRQ Medication Reconciliation Toolkit (KT-CQUIPS-85) Four New York Providers Use AHRQ … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety

40. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … Events Associated With Hip Joint Replacements 16,000 0.49 MPSMS (2015) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented