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141. 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.

142. 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?

143. 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

144. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
     June 01, 2023 - Expanding the scope to also include “problems” encourages reporting of adverse events where patients … Given the uncertainties inherent in diagnosis, a portion of adverse diagnostic events that are not … The literature on medical errors documents that the long-term harms associated with adverse events are … diagnostic events. … First, when patients experience adverse medical events, they frequently switch to alternative venues

145. 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.

146. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - ■ 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 6 – Facilitator Notes - Grand Rounds Presentation Say: A good response to adverse events … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events

147. Improving Patient Safety Systems for Limited English Proficiency Patients: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
     January 01, 2011 - 10 20 30 40 50 Pe rc en t Type of Physical Harm Types of Physical Harm Experienced From Adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … http://teamstepps.ahrq.gov/� http://teamstepps.ahrq.gov/� Summary  Adverse events that affect LEP … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Causes of Adverse Events for LEP and Culturally Diverse Patients Systems and Strategies To Improve Safety

148. 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.

149. 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

150. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
     January 01, 2016 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers and falls … For example, measured adverse drug events continued to drop from 2014 to 2016, while measured pressure … Infections (CLABSI) Clostridium difficile Infections Falls Obstetric Adverse Events Pressure Ulcers … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS, including those in the Surgical … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number

151. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=277
     January 01, 2024 - Keywords: Blood Pressure, Diagnostic Safety and Quality, Adverse Events, Medical Errors, Electronic … This study examined the reported adverse events (AEs) involving cataract surgery in Massachusetts from … Patient harm in cataract surgery: a series of adverse events in Massachusetts. … Keywords: Adverse Events, Eye Disease and Health, Patient Safety, Risk, Surgery Dabbous F , … Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.

152. 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.

153. 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

154. Effects of Sleep Loss and Night Work on Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-landrigan.html
     November 01, 2021 - events that we’ve been experiencing in this country for the past several decades." … events.  … In an initial nine-center study , rates of preventable adverse events fell 30 percent following implementation … events due to medical care. … Landrigan developed and tested a new trigger tool to identify adverse events in pediatric patients.

155. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

156. 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

157. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
     September 01, 2020 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Types of Physical Harm Experienced From Adverse Events by English Speaking and LeP Patients. … Common Causes: Adverse Events for LEP Culturally Diverse Patients Use of Family Members/Friends … Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care .

158. 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.

159. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.html
     August 01, 2022 - to establish an initiative to help States and health care systems test new models of care delivery, adverse … previously collected patient complaint data suggests that patient complaints may be a predictor of adverse … events. … drug events. … that would also be Automatically Compensable Events (ACEx2), a list of 18 events meeting these criteria

160. Patient and Family Engagement | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
     September 01, 2013 - Introduction to Adverse Events Slide 23. Immediate Response to an Adverse Event 4 Slide 24. … Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Medical providers are committed to caring for their patients; however, adverse events can happen. … The Second Victim: Health Care Workers 7 Say: Adverse events are often system failures. … Organizations need to engage in strategies to address adverse events.