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121. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.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

122. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.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

123. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.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

124. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.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.

125. Antibiotic Side Effects (pdf file)
     www.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

126. Making Effective Changes in Antibiotic Decision Making (pdf file)
     www.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

127. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     www.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

128. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     www.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.]

129. Mod4-Event-Checklist (pdf file)
     www.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

130. AHRQ-Funded Patient Safety Highlights: Improving Healthcare Safety by Supporting Measure Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
     August 01, 2025 - Events: Provided actionable insights into adverse events (e.g., medication adverse events, diagnostic … drug events related to narcotics showed a 49% reduction in narcotic-related adverse drug events, resulting … Events in the Nursing Home Setting 2016–2018 $1,493,927 Purpose: Describe adverse events that occur … Events 2015–2019 $1,500,000 Purpose: Give the first comprehensive perspective on adverse events that … events those reported adverse events.

131. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
     July 01, 2023 - Discuss how to communicate an adverse event to a patient and family members. … Engaging after an adverse event. Engaging in planning and design. … 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.

132. Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dierks-report.pdf
     January 01, 2024 - This enabled us to model the quasi-oscillatory nature of risk tolerance around adverse events, as … This means that clinical units that experience infrequent adverse events are assumed to be safe, even … This means that clinical units that experience infrequent adverse events are assumed to be safe, even … A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Healthcare Settings. … On Modeling Risk of Adverse Events in Complex Healthcare Settings.

133. Medical Injury Identification Using Hospital Discharge Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
     January 01, 2003 - adverse drug events or nosocomial infections. … Reporting of adverse events. NEJM 2002;347:1,633–8. 4. Halperin W. … Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical … Incidence and types of adverse events and negligent care in Utah and Colorado. … Measuring errors and adverse events in health care. J Gen Intern Med 2003;18:61–7.

134. Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/king-report.pdf
     January 01, 2024 - Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … (MODL-AF) Project Title: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … Proactive care (n = 4,530) 184/1,909 (9.64) 4.54 468/2,621 (17.86) 7.53 0.82 (0.68,0.98 ) Early outcome events … care (n = 4,939) 79/2,089 (3.78) 15.6 2 146/2,850 (5.12) 21.3 2 0.94 (0.70,1.25 ) Late outcome events

135. Candor-Impguide (pdf file)
     www.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

136. Puh-Factraining-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
     June 02, 2025 - Slide 6: On-Time Reports for Four Adverse Events SAY: There are four sets of On-Time reports to help … prevent four adverse events: pressure ulcers, pressure ulcers that are not healing appropriately, falls … Commitment to work with a Facilitator to learn how to use the reports to prevent adverse events. … The reports: Focus on preventing adverse events. Are proactive rather than reactive. … Improve root cause analyses when adverse events occur.

137. References | Agency for Healthcare Research and Quality
     www.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

138. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse … 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

139. Analyzing Big Datasets to Improve Healthcare Quality, Equity | Agency for Healthcare Research and Quality
     www.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

140. Mod03-Gap-Analysis-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
     April 01, 2016 - Identification and Analysis of Actual and Potential Adverse Events a. … Is there a process in place for identifying, managing, and analyzing adverse events, near miss events … Do staff have access to a system for reporting adverse events? c. … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events?