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141. 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.

142. 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

143. 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.]

144. 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

145. 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.

146. 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.

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

148. 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

149. 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.

150. 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

151. 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

152. 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

153. 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?

154. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Many clinical medicine organizations use institutional-level detection of adverse events, followed … Outside the VHA, after studying aggregate data on adverse drug events, it was determined that many … Understanding and responding to adverse events. N Engl J Med 2003;348(11):1051–6. 8. Nolan TW. … Systems analysis of adverse drug events. ADE Prevention Study Group. … Reporting of adverse events. N Engl J Med 2002;347(20):1633–8. 39.

155. Appendix B. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appb.html
     August 01, 2022 - Communication-sensitive adverse events and quality metrics: A retrospective database analysis in Washington … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … Integrated approach to reduce perinatal adverse events: Standardized processes, teamwork training, and … Incidence of adverse events and negligence in hospitalized patients.

156. Puh-Factraining-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
     June 02, 2025 - Events SAY: There are four sets of On-Time reports to help prevent four adverse events: …  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. … Slide 5: Discussion Slide 6: On-Time Reports for Four Adverse Events Slide 7: Common Elements of On-Time

157. Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdf
     January 01, 2024 - Handoff-related adverse events decreased by 42%. All changes were p < 0.05. … Handoff-related Adverse Events In total, 1698 reports of handoff-related adverse events were collected … Rate of handoff-related adverse events. … Reported as the number of events per person-year for both major and minor handoff-related adverse events … Does housestaff discontinuity of care increase the risk for preventable adverse events?

158. Patient Family Engagement PowerPoint Content and Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/alt-text-tab.html
     September 01, 2013 - tools to improve communication among patients, families, and clinicians Discuss how to communicate an adverse … event   Slide 22 Introduction to Adverse Events Adverse event: An injury to a … events happen When an adverse even occurs, it can be difficult for a health care worker to take ownership … event is essential   Slide 23 Immediate Response to an Adverse Event 3 Care for … events occur   Slide 28 Tools Am I Ready To Become an Advisor?

159. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017.html
     November 01, 2017 - Obstetric Adverse Events. Pressure Ulcers. Surgical Site Infections. … Bloodstream Infections          Falls          Obstetric Adverse Events          Pressure Ulcers … Central Line-Associated Bloodstream Infections Falls Obstetric Adverse Events Pressure Ulcers … Stream Infections (CLABSI) Falls Obstetric Adverse Events (OBAE) Pressure Ulcers Surgical Site … Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/or

160. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
     July 01, 2023 - Although patient and family conceptions of adverse events do not always conform to clinical definitions … But patients and families do not describe adverse diagnostic events with such uniformity. … A substantial body of literature addresses patient interactions with clinicians after adverse events … repeated adverse events may be particularly reticent to report those experiences. … Can we rely on patients’ reports of adverse events?