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Showing results for "adverse events".
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141. “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.

142. 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?

143. 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.

144. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - Measuring errors and adverse events. … events to study rates of serious medical errors and adverse events. … Detection of Errors and Adverse Events. … events, or adverse events; this step is ongoing. … Potential adverse events and adverse events are being rated on severity using a four-point Likert scale

145. 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?

146. 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

147. 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

148. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - The realization that adverse events often occur because of system breakdowns, not simply because of … Transparency and Learning The idea that adverse events could yield information was not new, but as it … The goal of the field of patient safety is to minimize adverse events and eliminate preventable harm … In this sense, patient safety espouses continuous cycles of learning, reporting of adverse events or … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 15.

149. 1 Preventablehospitaledvisits-Overview-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
     June 02, 2025 - Events SAY: Four sets of On-Time reports are available 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. … The goal is to focus on preventing adverse events. … • Improve root cause analyses when adverse events occur.

150. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     June 02, 2025 - Events SAY: There are four sets of On-Time reports to help prevent four adverse events: pressure …  Commitment to work with a Facilitator to learn how to use the reports to prevent adverse events … For example, for some adverse events, the dietitian is an important member of the team because declining … The reports:  Focus on preventing adverse events.  Are proactive rather than reactive. …  Improve root cause analyses when adverse events occur.

151. Final Progress Report: Improving the safety of pediatric tracheal intubation in ICUs with apneic oxygenation and video laryngoscopes (pdf file)
     www.ahrq.gov/sites/default/files/2025-06/nishisaki3-report.pdf
     January 01, 2025 - These pediatric-specific features increase risks and adverse events associated with TI procedures. … tracheal intubation associated events were reported in 5.7% of children without intervention from … events and severe events. … Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events … Hemodynamic Events.

152. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
     November 01, 2017 - Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/ … events included postpartum hemorrhage, preeclampsia/eclampsia, and anesthesia-related adverse events … adverse events as the end point. … events and the risk of death among women experiencing maternal adverse events. … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[

153. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
     November 01, 2017 - Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/ … events included postpartum hemorrhage, preeclampsia/eclampsia, and anesthesia-related adverse events … adverse events as the end point. … events and the risk of death among women experiencing maternal adverse events. … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[

154. 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?

155. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
     June 01, 2023 - clinicians typically focus on errors, that is, what they would perceive as preventable and harmful events … events. 35 A study of pediatric hospitalizations in the United States documented that family reports … identified five times as many errors and three times as many other adverse events as incident reports … A substantial body of literature addresses patient interactions with clinicians after adverse events, … repeated adverse events may be particularly reticent to report those experiences.

156. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - Key Words: patient safety, emergency medicine, errors, adverse events, harm Principal Investigator … Aim 2 – Compare errors and adverse events through active surveillance with those identified through … SCOPE In order to improve a system in any industry, the adverse events that take place within the system … Current knowledge about the number and types of errors and adverse events occurring within emergency … Only a small number of studies have evaluated the epidemiology of errors and adverse events within the

157. AHRQ Report to Congress Describes Sepsis’ Burgeoning Burden on Hospital Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/929.html
     September 01, 2024 - AHRQ Analysis Shows Progress in Reducing Patient Safety Events . … patients reveals a decline in adverse events since the peak of the COVID-19 pandemic, with a 13-to-15 … percent reduction in adverse events in 2022 compared to 2021. … The report, Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (PDF, 2 MB), was led … Among report highlights: in 2022, 6.2 percent of Medicare patients experienced at least one adverse event

158. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - event Slide 21 SAY: Adverse events occur when a patient is harmed as a result of receiving medical … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 25 SAY: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … events.

159. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
     August 01, 2022 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … Do: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. … events.”

160. 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?