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381. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - previously undetected adverse events. … The incidence and severity of adverse events affecting patients after discharge from the hospital. … The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice study … Incidence of adverse events and negligence in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

382. Understanding SOPS Surveys: A Primer for New Users - Famolaro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-4-famolaro-2018.pdf
     January 01, 2018 - SOPS to Hospital CAHPS patient experience • Hospital SOPS to AHRQ Patient Safety Indicator (PSI) adverse … Hospital SOPS & PSI Adverse Event Rates Higher patient safety culture scores associated with lower … adverse event rates r = -.36 0 2 4 6 8 10 12 14 16 18 40% 45% 50% 55% 60% 65% 70% 75% 80% … Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events. … Linking SOPS to Other Outcomes Hospital SOPS & Hospital CAHPS Patient Experience Hospital SOPS & PSI Adverse

383. Measure Descriptions for Daily Early Mobility: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-slides.html
     February 01, 2017 - Adverse events. Event types. … Slide 29: Events Image: Detail of the event reporting column from the data collection tool. … Can include up to three events if necessary. … Adverse event incidence rate (intubated and non-intubated). … Top 10 adverse events for ventilated and nonventilated patients.

384. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - Exploring relationships between hospital patient safety culture and adverse events. … Beliefs, behaviors reflect organizational ability to learn Associated with adverse events, patient satisfaction … Exploring relationships between hospital patient safety culture and adverse events. … events. … Reported Frequency of Events Reported Frequency of Events Reported Supervisor Manager Actions Promoting

385. Patient Imaging Quality and Safety Laboratory (PIQS Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html
     April 01, 2021 - The PIQs Lab assessed adverse event reports related to VIR over a 6-year period, finding that 45 percent … The most commonly reported adverse events were procedural complications (109; 29.1%), many of which had … Adverse events associated with peri-procedural handoffs, under review. 2020 Garry K, et al.

386. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
     October 01, 2017 - events? … events Through a noninvasive interface after HMV, BPAP, or CPAP Patients with chronic respiratory … (KQ 5) Adverse Events using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … events Timing • At least 1 month of treatment Setting • Home • Assisted living residence

387. Mod5-Disclosure-Checklist (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
     April 01, 2016 - ■ Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an adverse … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize ■ Say you are sorry for the adverse event in a sincere manner early in the conversation.

388. Disclosure Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an adverse … Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.   … Be honest EXPLAIN the facts about the adverse event without the patient having to do a lot of probing

389. PowerPoint Presentation (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-UTI-slides.PPT
     June 01, 2021 - not associated with increased morbidity or mortality Unnecessary antibiotics are associated with: Adverse … Events/Notes TMP-SMX (Bactrim) Oral Concentrates in urinary tract Hyperkalemia, rash, warfarin interaction … Events form and encourage staff to use this when a resident was harmed or had the potential to be harmed … of Antibiotic Decision Making Form Monthly Data Collection Form Learning From Antibiotic-Associated Adverse … Events 23 UTI Management 23 Disclaimer The findings and recommendations in this presentation

390. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/references.html
     July 01, 2022 - The costs of adverse drug events in hospitalized patients. … Adverse Drug Events Prevention Study Group. JAMA 1997; 277(4):307-11. … Identifying hospital admissions due to adverse drug events using a computer-based monitor.

391. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/references.html
     July 01, 2022 - The costs of adverse drug events in hospitalized patients. … Adverse Drug Events Prevention Study Group. JAMA 1997; 277(4):307-11. … Identifying hospital admissions due to adverse drug events using a computer-based monitor.

392. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
     April 06, 2008 - events, but also information derived from the several sources. … events. … events. … In this incident causation model, near misses are precursors to possible adverse events. … events.

393. Program-Dev-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-facilitator-guide.docx
     June 01, 2021 - provide oversight through quality improvement activities such as reviewing medications, monitoring for adverse … necessary, thereby protecting residents from unnecessary antibiotic exposure and antibiotic-associated adverse … It can be helpful to separate the events into “pre-prescriptive” events, which are the events prior to … A reduction in adverse events means improved resident safety and sometimes cost savings. … antibiotics · Use of guideline-concordant antibiotics · Clostridioides difficile infection rates · Adverse

394. Appendix A. Flow Chart for Implementing Universal Decolonization | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apa.html
     September 01, 2013 - Safety and Adverse Events

395. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
     March 31, 2008 - events or adverse patient outcomes, including events with and without identified errors, across all … Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556-1564. 7. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Classification of medical errors and preventable adverse events in primary care: A synthesis of the … Adverse events in primary care identified from a risk- management database.

396. Final Progress Report: Patient-Centric Risk Model for Medication Safety During Care Transitions (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurses-report.pdf
     January 01, 2024 - A theoretical framework of risks and hazards for medication-related adverse events. Table 1. … drug events Medical records (as documented by providers) Patient reporting of adverse drug events … Care transitions pose high risk for adverse drug events. … National surveillance of emergency department visits for outpatient adverse drug events. … Risk factors for hospital admissions associated with adverse drug events.

397. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - suffer a medication error2 On average, every patient admitted to an intensive care unit suffers an adverse … Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34. … An alternative strategy for studying adverse events in medical care.

398. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - While the vast majority of medication errors do not result in adverse patient outcomes, various studies … Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995;274(1):35–43. 3. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … MedWatch, the FDA safety information and adverse reporting program. … USP launches MEDMARX as the third major national reporting program for adverse drug events; 1998.

399. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
     January 01, 2024 - that raised awareness, encouraged reporting, and built skills to address errors and adverse events … events. … events. … events. … events.

400. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - clinician attitudes about the disclosure of individual, team, and system failures associated with four adverse … members tended to agree on which system failures were important to disclose, regardless of the type of adverse … Clinician responses were more varied and were affected by type of adverse event, but they did agree with … events, and conducting clinical safety interventions. … transitioning from hospital to home care to determine the potential for discrepancies to result in an adverse