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121. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
     January 01, 2024 - Primary outcomes included teamwork climate and adverse events. … to detect adverse events. … We calculated estimated proportions of occurrence of adverse events. … one or more adverse events. … Exploring the causes of adverse events in NHS hospital practice. J R Soc Med.

122. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - 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 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 Say: A good response to adverse events really hinges on knowing about them immediately … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events

123. 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.

124. Declines in Hospital Acquired Conditions (pdf file)
     www.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

125. Improving Patient Safety Systems for Limited English Proficiency Patients
     www.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.

126. About the Toolkit Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - Background Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse … that between 2004 and 2014, poor communication was a root cause of 48 percent of sentinel maternal events … 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.

127. 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

128. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - References Patient perspectives offer unique information about how diagnosis-related events … enrich clinicians’ understanding of patient and family experience and reduce the harms that follow adverse … diagnostic events. … Although patient and family conceptions of adverse events do not always conform to clinical definitions … diagnostic errors, it is important to identify and understand the broader scope of patient-defined adverse

129. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - Key Words: adverse events, emergency department, trigger tool 3. … Triggers associated with adverse events on bivariate analysis Trigger Pop. Freq. … Adverse events related to emergency department care: a systematic review. … A trigger tool to identify adverse events in the intensive care unit. … The incidence and nature of in-hospital adverse events: a systematic review.

130. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/25649-O'%20Leary-draft-1.pdf
     March 16, 2023 - Primary outcomes included teamwork climate and adverse events. … to detect adverse events. … We calculated estimated proportions of occurrence of adverse events. … one or more adverse events. … Exploring the causes of adverse events in NHS hospital practice. J R Soc Med.

131. 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

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. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/preface.html
     May 01, 2016 - and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … demonstrated the feasibility and promise of collecting information from health care professionals about adverse … data about concerns that patients have about the safety of their health care, including errors and adverse … events.

134. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
     May 01, 2017 - 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.

135. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - their expectations. 11 Therefore, systematic elicitation of patients’ experiences related to safety events … diagnostic breakdowns during transitions among clinical settings. 19 , 25 Assessing the impact of adverse … events on the health and well-being of patients. 26 Understanding the impact of diagnostic problems … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors … But patients and families do not describe adverse diagnostic events with such uniformity.

136. 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

137. 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

138. Cover slide
     www.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?

139. 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.

140. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - Detecting adverse events for patient safety research: a review of current methodologies. … Detecting Adverse Events Using Information Technology. … Detection of adverse events using conflicts in the electronic medical record (poster). … Using computerized data to identify adverse drug events in outpatients. … Electronically screening discharge summaries for adverse medical events.