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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.
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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.
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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
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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
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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.
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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
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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?
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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?
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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?
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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
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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
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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
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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
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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
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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.
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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
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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.
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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
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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
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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.