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181. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
     April 01, 2025 - Unlike safety “events,” diagnostic errors tend to become evident over time and across different sites … Adverse Events, Diagnostic Adverse Events Defined under the Safety Paradigm section above, adverse event … to an event that results in unintended harm encountered during medical care. 3 In general, medical adverse … events tend to be (but are not always) errors of commission (e.g., wrong site surgery). … Diagnostic adverse events commonly include errors of omission (e.g., failure to order or properly interpret

182. Prologue | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/prologue.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Events in Labor and Delivery Patient Safety Culture and Medical Liability—Recommendations for Measurement … Drug Events During Transfer of Care from Hospital to Home Kenneth Sands, Alan Woodward … culture among staff in medical institutions, to find lasting and systemic prevention strategies for adverse … events, and to work with patients—and with their families and caregivers—as equals to both address their

183. Improving Antibiotic Use is a Patient Safety Issue
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
     November 01, 2019 - Events Improving Antibiotic Use – Patient Safety Issue AHRQ Safety Program for Improving Antibiotic … Use – Acute Care 5 5 Antibiotic-Associated Adverse Events In a cohort of ~1,500 hospitalized patients … developed antibiotic-associated adverse events after hospital discharge Most adverse events had some … Approximately 20% of hospitalized patients develop antibiotic-associated adverse events. … Association of Adverse Events with Antibiotic Use in Hospitalized Patients.

184. 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

185. Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/summary.html
     May 01, 2016 - out by the Institute of Medicine, 2   and the AHRQ Common Formats, a which includes definitions of adverse … events and forms for adverse event reporting. … any relevant information collected from other sources within their organizations (such as an existing adverse … the identified goals (patient safety improvement, public monitoring and accountability, research on adverse … Overall, the number of consumer reports was disappointing, given the potential reservoir of adverse events

186. Data Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/resources/index.html?page=0
     HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about adverse … events and patient safety-related events in U.S. hospitals. … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries

187. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/areas/improve-discharge.html
     August 01, 2024 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … Events After Discharge Transitions of Care Project BOOST (Better Outcomes for Older Adults through Safer … Events With AHRQ Medication Reconciliation Toolkit (KT-CQUIPS-85) Four New York Providers Use AHRQ … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety in the

188. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/about/patient-safety-culture.html
     June 01, 2024 - rates. 2 Hospitals with more positive SOPS scores had: Lower rates of in-hospital complications or adverse … events as measured by AHRQ’s patient safety indicators (PSIs). 3 Patients who reported more positive … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.

189. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - It is estimated that one in seven patients is affected by adverse events, and that as many as half of … Module 6 7 As referenced in Module 3, this diagram shows the distinction between adverse events and … errors, and recognizes that not all adverse events are medical errors, and not all medical errors are … adverse events. … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

190. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
     August 01, 2022 - Assessment of rates of communication-sensitive adverse events. … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … events and maternal adverse events. … Incidence of adverse events and negligence in hospitalized patients.

191. AHRQ HAC 2015 Interim Data Graphic V03C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-infographic-2015.pdf
     January 01, 2015 - 21%21% LIVES SAVEDLIVES SAVED 125,000125,000 IN SAVINGSIN SAVINGS $28 BILLION $28 BILLION FEWER ADVERSE … EVENTS FEWER ADVERSE EVENTS 3 MILLION3 MILLION From 2010–2015, more than 3 million hospital-acquired

192. Toolkit Implementation Guide for Acute Care Antibiotic Stewardship Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/acute_care_implementation_guide.pdf
     November 01, 2019 - events as well as first and second order problem solving approaches. … o “Learning From Antibiotic-Associated Adverse Events Form” is similar to a root cause analysis form … events. … changes.html https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/identifying-antibiotic-adverse-events-form.docx … https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx

193. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/measures/global-assessment.html
     August 01, 2021 - Pediatric Patient Safety PQMP COE:  CEPQM Associated NQF # and Name:  3136, GAPPS: Rate of Preventable Adverse … Events Per 1,000 Patient-Days Among Pediatric Inpatients Products: Full Report  (PDF, 289.7 KB)

194. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
     May 01, 2017 - Events An adverse event is an injury to a patient caused by medical intervention rather than by the … The mission of health care providers is to help and care for patients without harming them, but adverse … events happen. … Prompt, compassionate, and honest communication with the patient and family after an adverse event is … Organizations should be prepared to respond and communicate proactively when adverse events occur.

195. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/safety/index.html
     June 01, 2021 - Use Commitment Poster (DOCX) Antibiotic Time Out Tool (DOCX) Identifying Antibiotic–Associated Adverse … Events Form (DOCX) Learning From Antibiotic–Associated Adverse Events Form (DOCX)

196. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Illinois, New York, and Pennsylvania require that adverse events be disclosed to patients. … errors and preventable adverse events, and 3 years of adverse event reports to the New York Patient … JCAHO and New York are the only agencies that address the full range of adverse events, and JCAHO’s … Defining reportable adverse events: a guide for States tracking medical errors. … Patient safety: reporting of adverse events, NEJM 2002; 347(20):1,633–9. 39.

197. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
     September 01, 2017 - Slide 6: On-Time Reports for Four Adverse Events Say: Four sets of On-Time reports are available … 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.

198. Table of Contents: Volume 1. Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     January 01, 2025 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November, … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … News Media and Health Care Providers at the Crossroads of Medical Adverse Events Pamela Whitten, Mohan … Mahoney Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from … Drug Events: Study Methods Andrew L.

199. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
     January 01, 2025 - Drug Events: Study Methods Andrew L. … ix Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … News Media and Health Care Providers at the Crossroads of Medical Adverse Events Pamela Whitten, Mohan … Mahoney Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from

200. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Detecting adverse events for patient safety research: a review of current methodologies. … Measuring errors and adverse events in health care. J Gen Intern Med  2003;18(1):61-7. … Lessons from a patient partnership intervention to prevent adverse drug events. … Computerized surveillance of adverse drug events in hospital patients. … Adverse events during hospitalization: results of a patient survey.