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101. Appendix: Incidence of Hospital-Acquired Conditions in the Partnership for Patients: Estimates and Projected and Measured Impact | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2014-ap1.html
     November 01, 2015 - 5,000 0.2 Falls MPSMS (2014) In-Hospital Patient Falls 260,000 7.9 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 74,000 2.3 MPSMS (2014) Adverse … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated … Goal for HAC Reduction f PfP HAC Reduction Goal g Estimated PfP Additional Cost* per HAC Adverse … 25% 10,000 $17,000 Falls 200,000 25% 50% 12.5% 25,000 $7,234 Obstetric Adverse

102. PowerPoint Presentation
     www.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.

103. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
     www.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.

104. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - A popular method is to examine adverse events that have occurred and “trace back” to attempt to pinpoint … The state-of-the-art in patient safety efforts emphasize retrospective analysis of adverse events or … When adverse events do occur, it may be difficult retrospectively to accurately determine their etiology … NRE encompass a substantially larger class of events than adverse events, medical errors, or even “near … Cheney FW, Posner KL, Caplan RA: Adverse respiratory events infrequently leading to malpractice suits

105. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
     www.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.

106. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
     www.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 … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharges Adverse … 0.51 Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … 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

107. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     www.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.

108. Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013-appendix.html
     October 01, 2015 - 9,200 0.28 Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse … 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 … Measured HACs c Projected Cost Savings in 2013 d Projected Reductions in Deaths in 2013 e Adverse … Goal for HAC Reduction b PfP HAC Reduction Goal c Estimated PfP Additional Cost* per HAC Adverse

109. PowerPoint Presentation
     www.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

110. Final Progress Report: Conference on Medical Error Communication and Dispute Resolution (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/liebman-hyman-report.pdf
     January 01, 2024 - of individuals from various disciplines to share information about disclosure of medical errors and adverse … events, use of alternative dispute resolution rather than litigation to resolve medical malpractice … events and from the resolution of a medical malpractice claim through mediation. … Presenters explored the benefits and risks of apology and disclosure after an adverse event or medical … events.

111. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
     November 30, 2010 - at High Risk of Adverse Drug Events: Study Methods Andrew L. … Six hundred subjects at high risk of adverse drug events (ADEs) will be enrolled across three study … The costs associated with adverse drug events among older adults in the ambulatory setting. … Risk factors for adverse drug events among older adults in the ambulatory setting. … Strategies for detecting adverse drug events among older persons in the ambulatory setting.

112. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - 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.

113. Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
     December 01, 2014 - Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse … 9,200 0.28 Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse … Events PSI (2012) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) … 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

114. Validation of AHRQ’s Patient Safety Indicator for Accidental Puncture or Laceration (pdf file)
     www.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

115. Declines in Hospital-Acquired Conditions (pdf file)
     www.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

116. Open Wide Learning Lab (OWLL): Improving Patient Safety in Dentistry | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/owll-long-desc.html
     August 01, 2025 - aimed to improve patient safety in dental settings by establishing a learning health system that used adverse … Identifying contributing factors associated with dental adverse events through a pragmatic electronic … An observational retrospective study of adverse events and behavioral outcomes during pediatric dental … Identifying contributing factors associated with dental adverse events through a pragmatic electronic … An observational retrospective study of adverse events and behavioral outcomes during pediatric dental

117. Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care (pdf file)
     www.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.

118. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
     August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … institutions include how to: Engage patients and families in disclosure communication following adverse … events. … Implement a Care for the Caregiver program for providers involved in adverse events. … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

119. 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 - 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.

120. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.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.