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181. 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.”

182. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-tracking-tool-skilled-nursing-facilities.pdf
     December 01, 2021 - This is important because if you are seeing increased adverse events related to a specific vaccine … This is important because if you are seeing increased adverse events related to a specific vaccine administrator … Events by Manufacturer. … Figure 16 – Example Adverse Events pie chart This tool is voluntary and not related to any interim … Events following COVID-19 Vaccine(s).

183. 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

184. AHRQ Views Blog: At the American Society of Health Economists Conference, AHRQ Highlights Its Deep Dive Into COVID-19 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/868.html
     June 01, 2023 - Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Did Not Adverse tracheal intubation-associated events—unwanted events that occur as a result of the … tracheal intubation-associated events. … events.

185. Puh-Factraining-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
     November 24, 2014 - 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.

186. On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
     December 01, 2017 - 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 … 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.

187. “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.

188. Pf-Engagement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
     May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care. … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 21 SAY: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … Organizations need to engage in strategies to address adverse events.

189. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/summary.html
     May 01, 2016 - 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

190. 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

191. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
     December 01, 2012 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: Systems … Identify common causes of adverse events for LEP and culturally diverse patients. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Return to Contents Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Use … Language proficiency and adverse events in U.S. hospitals: a pilot study.

192. Understanding SOPS Surveys: A Primer for New Users (Webcast) - Famolaro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-SOPS_101_Webcast-FAMOLARO.pdf
     January 01, 2020 - 2.0 Webcast Replay, PowerPoint slides, and Transcript are available on the AHRQ SOPS website under Events … Hospital SOPS to AHRQ Patient Safety Indicator (PSI) adverse event rates 3. … Journal of Patient Safety. 8(3), 131-139. 38 HSOPS 1.0 & Patient Safety Indicator (PSI) Adverse Event … en t R at e— PS I C om po si te Higher patient safety culture scores associated with lower adverse … Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events.

193. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
     July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview Advancing Excellence … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … events. … view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse … events.

194. Patient Safety Information for Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/monahrq/myqi/safety_prov.html
     June 01, 2021 - events occur that cause harm to patients. … Top   Improving How Care Is Provided Preventing and Managing Medical Errors Medical errors are adverse … patient events that could have been prevented. … Free abridged report on 34 NQF practices to reduce adverse events Learn how checklists help prevent … Learn more about safety culture 10 patient safety tips from AHRQ for hospitals to prevent adverse

195. 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.

196. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pptx
     March 04, 2016 - During that same period, adverse drug events decreased from a rate of 49.5 per 1,000 discharges (more … events Percentage of adults with mechanical adverse events associated with central venous catheter … Adverse events occurring the day of hospital arrival were excluded. … , 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.

197. 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.

198. 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

199. 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.

200. 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