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221. 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.

222. 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

223. Engage Patients and Families for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
     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. … 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.

224. Prologue: 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/Advances-Prologue_Grady_Vol4.pdf
     June 02, 2025 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … drug events; reduce costs through streamlining processes and providing more targeted, efficient care … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … drug events.

225. 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.

226. 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

227. AHRQ National Scorecard on Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/index.html
     July 01, 2020 - Condition Rate ( PDF , 237 KB) To improve how the Nation tracks its progress on reducing HACs and other adverse … events, AHRQ is developing the AHRQ Quality and Safety Review System . … This patient safety surveillance system will capture information about HACs and other adverse events

228. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - The IOM has called for a reporting system that includes both adverse events and near misses. … A physician- based voluntary reporting system for adverse events and medical errors. … Confidential clinician-reported surveillance of adverse events among medical inpatients. … Adverse drug events in primary care. N Engl J Med. 2003; 348: 1556-1564. 15. … Will, ideas, and execution: Their role in reducing adverse medication events.

229. 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.

230. 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

231. 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.

232. 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)

233. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … Potential decrease in adverse events being litigated, which can lead potentially led to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … events really hinges on knowing about them immediately.

234. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2013.html
     November 01, 2015 - Half of these inpatients experienced one or more adverse events that resulted in a prolonged hospital … events—such as adverse drug events, falls, and pressure ulcers—occurred. … Data for obstetric adverse events come from AHRQ Patient Safety Indicators (PSIs) 18 and 19. … events. … events.

235. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - Thus, a subcategory of adverse events ascribed to error or substandard care, called preventable adverse … Few investigators focus on these types of diagnostic adverse events. … Adverse Events, Diagnostic Adverse Events Defined under the Safety Paradigm section above, adverse … Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients.

236. Section 7C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
     June 02, 2025 - Table VII.C.1 – Distribution of insurance types and adverse … events across sites based on GAPPS study analytic sample (n = 3,151) Insurance n (%) AE rate P-Value … 58.2%) 0.10 <0.001 No Insurance 102 (3.2%) 0.04 0.001 Table VII.C.2 – Analysis of differences in adverse

237. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … By addressing common, preventable adverse events, a health care setting can become safer, thereby enhancing … More than three-fourths of PSOs offered analytical support for adverse events, and a similar share … “The Importance of Reporting Safety Events.” 2014. Analytic Support for Adverse Events. … Copyright 2015 ECRI Institute. www.ecri.org • Adverse events • Near misses • Hazards • Common Formats

238. Return on Investment Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

239. Table 7.A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
     June 02, 2025 - Table VII.A.1 – Distribution of race/ethnicity and adverse … events across sites based on GAPPS study analytic sample (n = 2,834) Race/Ethnicity n (%) AE rate … Hispanic 352 (12.4%) 0.18 <0.001 Other 161 (5.7%) 0.12 0.12 Table VII.A.2 – Analysis of differences in adverse

240. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     June 02, 2025 - RTI) and Consumers Advancing Patient Safety, Designing Consumer Reporting Systems for Patient Safety Events … for an ideal reporting system that consumers could use to report experiences with 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