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161. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
     July 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 always … The literature on medical errors documents that the long-term harms associated with adverse events are … First, when patients experience adverse medical events, they frequently switch to alternative venues … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review

162. 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

163. 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?

164. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
     August 01, 2022 - It is estimated that one in seven patients is affected by adverse events, and that as many as half of … events and errors, and recognizes that not all adverse events are medical errors, and not all medical … errors are adverse events. … Providers can also experience profound problems after adverse events that were not associated with medical … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

165. AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/index.html
     July 01, 2023 - Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse … events and associated systemic and contextual factors.

166. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … Events Associated With Hip Joint Replacements 16,000 0.49 MPSMS (2015) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented

167. Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2023-virtual-research-meeting-summary-patient-experience.pdf
     January 01, 2023 - Black adults, compared to White adults, are more likely to report preventable adverse events. … events for patients. … events, and reduce racial disparities. … Patients perceive that issues arise due to a combination of errors/adverse events and communication … We make the case (a) that patient 14 safety surveys must inquire about all adverse events, not

168. 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.

169. 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.

170. 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.”

171. 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.

172. Choosing an Intervention and Measuring Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
     June 01, 2021 - The Staff Safety Assessment Form and the Learning from Antibiotic-Associated Adverse Events Form … Staff Safety Assessment Form (DOCX, 330.3 KB) Learning From Antibiotic-Associated Adverse Events Form

173. Staff-Safety-Assessment (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/staff-safety-assessment.docx
     June 01, 2021 - Safety Assessment PURPOSE OF THIS FORM: To discuss issues that may result in antibiotic-associated adverse … events or have the potential to cause adverse events that could negatively impact patient safety.

174. 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

175. 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.

176. 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”[

177. 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”[

178. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/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.

179. 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.

180. ChartBook On Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
     March 04, 2016 - events  Percentage of adults with mechanical adverse events associated with central venous catheter … Adverse Events Associated With Central Venous Catheter Placement Adults with mechanical adverse events … , and other cardiovascular adverse events (Chiu, et al., 2015) … To decrease the likelihood of adverse events, catheters should be used for less than 90 days. … Adverse Drug Events Measures of Patient Safety in the Hospital Setting: Adverse Drug Events Patient