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301. Detailed Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
     August 01, 2022 - The grantee reported the following findings about the first 125 adverse events resolved through the communication … events). … Communication-sensitive adverse events (CSAEs). 9 the term “CSAE” was coined by the UW project and defined … The grantee reported findings on four composite scores that measure perinatal adverse events: the Adverse … The thinking was that the DRPs would be utilized by the hospitals to disclose adverse events, and the

302. Strategy 4: IDEA Discharge Planning (Tool 3) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
     January 01, 2010 - engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.

303. Acknowledgments | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/acknowledgements.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 … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home Advances in Patient Safety

304. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap2.html
     December 01, 2014 - vs. 2010, and Baseline Projections Made in 2011 on the Additional Inpatient Mortality per HAC Adverse … Drug Events 1,621,000 1,320,000 301,000 19% $1,505,000,000 6,020 Catheter-Associated … $149,600,000 1,628 Falls 260,000 240,000 20,000 8% $144,680,000 1,100 Obstetric Adverse … Events (2012 data used in lieu of 2013) 82,000 77,000 5,000 6% $15,000,000 7 Pressure

305. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - events focus on re-education, re-training, disciplinary actions, or the creation of new policies. … A pre-scripted immediate response to events, along with a tightened timeline for event reviews. … event or near miss is the prevention of future adverse events. … If these factors can be identified and modified, the chance of similar events can be reduced. … The systems approach recognizes that all adverse events have multiple contributing factors, many of which

306. Table 7.B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-6b-table-b1.pdf
     June 02, 2025 - Table 7.B Table VI.B.1 Identifying a record with one or more adverse … events Specificity Sensitivity Internal primary reviewers vs External expert primary reviewers 0.91

307. Final Progress Report: Automated Lab Test Followup To Reduce Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/greenes-report.pdf
     January 01, 2025 - As a secondary measure, rates of adverse events were calculated. … As secondary analysis, we will compare the rates of adverse events in Phases 2 and 3. … Although we attempt to detect adverse events attributable to these errors, we expect these adverse … Our study may not have adequate power to detect a difference in rates of adverse events. … Thus, our study may lead to a decrease in the rate of resulting adverse events.

308. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse Patient Safety

309. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
     January 01, 2017 - events Events causing mobilization episode to stop Intervention Agitation (1) Control Agitation (2) … 9 patients had 14 adverse events (<1% of activities) Falls to knees without injury (5) Systolic blood … events 6. … events ranged from agitation to transient physiological events to dislodgements and to falls (none of … the falls were considered serious) Adverse events ranged from 2.3 to 8.7 per 100 patients3-5 3.

310. 2018 National Healthcare Quality and DIsparities Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-final-es.pdf
     September 01, 2019 - Patient Safety Importance of Patient Safety Mortality Prevalence Cost Findings on Patient Safety Adverse … Events With Knee Replacement Adverse Events With Hip Replacement Adverse Drug Events With Heparin … Fibrinolytic Medication for Heart Attack Disparities for Asians Largest Disparities Anticoagulant-Related Adverse … Drug Events Treatment by Home Health Providers Providers With Language Assistance Trends in Quality

311. The Five Principles of Effective Primary Care-Based Care Coordination for Reducing Potentially Preventable Readmissions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
     March 01, 2021 - events. … If left unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … events. … events increases after hospitalization. … events.

312. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
     June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form Changing the System 12 What Happened? … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.   … Completion Guide for the Four Moments of Antibiotic Decision Making Form Learning From Antibiotic-Associated Adverse … Events Changing the System 19 Disclaimer The findings and recommendations in this presentation

313. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
     April 01, 2025 - Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients. … Patient record review of the incidence, consequences, and causes of diagnostic adverse events. … “Never events” and the quest to reduce preventable harm. … Serious Reportable Events in Healthcare 2011.  

314. Highlights From AHRQ's Patient Safety Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/psnet.html
     March 01, 2025 - related to patient safety, features a new set of articles including: Ambulatory medication errors and adverse … events involved in medicine-related malpractice cases from 2011 to 2021 .

315. Transforming Care for People Living with Multiple Chronic Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
     November 17, 2020 - risk” will go on to develop MCC • Targeted interventions to improve health and reduce the risk of adverse … events and complications among those with multiple chronic conditions (e.g., diabetes, depression, … interventions for those who have complex management issues and who are at “high risk” for avoidable adverse … events, and require a focus on preventing decline, maximizing functioning, and improving quality of

316. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.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 Carole Hemmelgarn Three … Some of the key elements of CRPs are reporting and responding to adverse events, continuous communication … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals.

317. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2014.html
     January 01, 2018 - events. … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … drug events (ADEs), although declines in other HACs also contributed significantly to deaths averted … events were less frequent at hospitals that have implemented a full EHR.

318. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
     January 01, 2024 - drug events or potential adverse drug events by the physician reviewers. … The combined incidence rate of adverse drug events and potential adverse drug events in the intervention … Emergency hospitalizations for adverse drug events in older Americans. … Adverse events among medical patients after discharge from hospital. … Adverse drug events resulting from patient errors in older adults.

319. Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
     March 10, 2008 - These tools can be used to help hospitals identify potential adverse events that might need further … study and also to enable users to assess the occurrence of in-hospital adverse events using routinely … Adverse events among medical patients after discharge from hospital. … The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Knowledge translation and patient safety: The Canadian adverse events study.

320. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - The nature of adverse events in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 16. … Medication errors and adverse drug events in pediatric inpatients. … The costs of adverse drug events in hospitalized patients.