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181. 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.

182. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
     December 01, 2014 - Slide 6: On-Time Reports Being Developed for Four Adverse Events Say: On-Time reports are being … developed to help prevent four adverse events: pressure ulcers, pressure ulcers that are not healing … 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. … Remind staff members that the On-Time reports can help identify risk for adverse events and that using

183. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - events. … About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that have implemented

184. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - 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.

185. 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

186. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - In 1998 there were 28 (14 percent) adverse events (patient minimally effected) and 25 (9 percent) in … 2001, compared with a rate of 86.00 near misses and 14.00 adverse events in 1998 (Table 1). … Incident type 1998 2001 Near misses 86.00 90.94 Adverse events 14.00 9.06 Figure 3. … Potential identifiability and preventability of adverse events using information systems. … Rate of near misses and adverse events per 100 incident Table 2.

187. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - as from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.

188. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - Results: Twenty-one cases (12 medical, 9 surgical) representing adverse events were presented at the … Adverse events triggering case selection included unexpected deaths (six), unplanned intubations (two … MM&I Results Twenty-one cases representing adverse events were presented in the MM&I conference series … Adverse events triggering case selection are listed in Table 2. … Adverse events triggering case presentations Case N Unexpected deaths 6 Unplanned intubation

189. Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/king-report.pdf
     January 01, 2024 - Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … (MODL-AF) Project Title: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation … Proactive care (n = 4,530) 184/1,909 (9.64) 4.54 468/2,621 (17.86) 7.53 0.82 (0.68,0.98 ) Early outcome events … care (n = 4,939) 79/2,089 (3.78) 15.6 2 146/2,850 (5.12) 21.3 2 0.94 (0.70,1.25 ) Late outcome events

190. 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.

191. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Detecting adverse events using information technology. … Adverse Events in Hospitals: Methods for Identifying Events. … Adverse events among children in Canadian hospitals: The Canadian Paediatric Adverse Events Study. … Adverse events and preventable adverse events in children.

192. 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.

193. Is There an Association Between Patient Safety Indicators and Hospital Teaching Status? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
     April 28, 2008 - Conclusion: Further research is needed on the relationship of residency programs to adverse events. … For example, older and sicker patients are often at higher risk for incurring adverse events.4, 7, 8 … Postoperative adverse events in teaching and nonteaching hospitals. … Patient risk factors for adverse drug events in hospitalized patients. … Hospital ownership and preventable adverse events. J Gen Intern Med 2000; 15: 211-219. 24.

194. Early Mobility in the Intensive Care Unit: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-fac-guide.html
     February 01, 2017 - Slide 11: Safety Say: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 14: Adverse Events Say: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

195. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … The system should collect information on all types of events, ranging from near-miss and no-harm events … to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse

196. Data Measures Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
     January 01, 2017 - Event Incidence Rate Numerator Total number of adverse events which occurred during mobilization … Events Numerator Total number of adverse events in each of the 25 categories which occurred during … /Trach & Mech Vent were marked “Y” Example Display top 10 adverse events. … event occur Target Low adverse event rate Mobility NOT Intubated: Distribution of Adverse Events … Events (cont) Example Display top 10 adverse events.

197. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - Compared to other industries, medicine has a relatively high rate of serious errors and adverse events … The most common causes of adverse events were medication use, wound infections, operative complications … In a study of ADEs in a 700-bed hospital, adverse drug events (ADEs) and preventable ADEs were estimated … Preventable adverse events were not significantly different. 10 When broadening the assessment to … No adverse events occurred.

198. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
     January 01, 2017 - Slide 10 Safety SAY: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 13 Adverse Effects SAY: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

199. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely … Because adverse events usually occur as a result of multiple failures, it is imperative that medical … events occur. … events. … events are not the result of one mistake.

200. 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