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201. Review Finds Similar Outcomes for Partial, Whole Breast Irradiation for Early-Stage Breast Cancer | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/breast-cancer-review.html
     February 01, 2023 - systematic review, from AHRQ’s Effective Health Care Program, also found PBI had significantly fewer acute adverse … events than WBI, though there was no apparent difference in late adverse events.

202. 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.

203. Tennessee Hospital Association Uses AHRQ Tools To Boost Patient Safety, Saving $17 Million | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201702.html
     March 01, 2017 - and safety unit of the Tennessee Hospital Association (THA)—helped 120 member hospitals reduce safety events … Among others, these safety challenges included: Adverse drug events. … Obstetrical adverse events. Pressure ulcers. Surgical site infections. … Patient Safety Organization (PSO), Re-Engineered Discharge (RED) Topic(s): Adverse … Drug Events (ADE), Healthcare Costs, Healthcare-Associated Infections (HAIs), Quality of

204. 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

205. 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.

206. Data Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/resources/index.html
     February 06, 2025 - 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

207. Mod03-Gap-Analysis-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
     April 01, 2016 - Identification and Analysis of Actual and Potential Adverse Events a. … Is there a process in place for identifying, managing, and analyzing adverse events, near miss events … Do staff have access to a system for reporting adverse events? c. … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events?

208. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
     July 01, 2023 - Although patient and family conceptions of adverse events do not always conform to clinical definitions … But patients and families do not describe adverse diagnostic events with such uniformity. … A substantial body of literature addresses patient interactions with clinicians after adverse events … repeated adverse events may be particularly reticent to report those experiences. … Can we rely on patients’ reports of adverse events?

209. Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdf
     January 01, 2024 - Handoff-related adverse events decreased by 42%. All changes were p < 0.05. … Handoff-related Adverse Events In total, 1698 reports of handoff-related adverse events were collected … Rate of handoff-related adverse events. … Reported as the number of events per person-year for both major and minor handoff-related adverse events … Does housestaff discontinuity of care increase the risk for preventable adverse events?

210. 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

211. 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

212. 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

213. Data Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/resources/index.html?page=0
     November 26, 2023 - 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

214. 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

215. Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/wessell2-report.pdf
     January 01, 2024 - Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids … in Primary Care Final Progress Report Reducing Adverse Drug Events from Anticoagulants, Diabetes … STRUCTURED ABSTRACT Purpose and Scope: Reducing harm from adverse drug events (ADEs) is a national … Emergency Hospitalizations for Adverse Drug Events in Older Americans. … Trends in adverse events over time: why are we not improving? BMJ Quality & Safety.

216. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/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

217. 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.

218. 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

219. Puh-Factraining-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
     December 15, 2016 - Events SAY: There are four sets of On-Time reports 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. …  Improve root cause analyses when adverse events occur. … Slide 5: Discussion Slide 6: On-Time Reports for Four Adverse Events Slide 7: Common Elements of On-Time

220. 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.