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41. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
    April 01, 2004 - Case Definitions (and Guidelines) for Adverse Events Following Immunization Katrin S. … Safety can only be inferred indirectly from the relative absence of multiple, likely adverse events … Case Definitions for Adverse Events After Immunization 91 Global standardization in immunization … Case Definitions for Adverse Events After Immunization 101 23. Rigau-Perez JG, Bonilla GL. … Surveillance of adverse events following immunization.

42. Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
    March 01, 2020 - Reducing Adverse Drug Events in Older Adults Reducing Adverse Drug Events in Older Adults 9-1 9. … Adverse Drug Events in U.S. … Reducing Adverse Drug Events in Older Adults PRISMA Diagrams Figure A.1: Reducing Adverse Drug Events … Reducing Adverse Drug Events in Older Adults Evidence Tables Table B.1: Reducing Adverse Drug Events … Reducing Adverse Drug Events in Older Adults Search Terms

43. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
    January 01, 2003 - Introduction Adverse drug events (ADEs) contribute to overall morbidity and mortality. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … Adverse drug events in ambulatory care. NEJM 2003;348:1,556–64. 4. … Multifacted approach to reducing preventable adverse drug events. … Relationship between medication errors and adverse drug events.

44. Safety Net | Agency for Healthcare Research and Quality
    www.ahrq.gov/topics/safety-net.html
    Connecticut Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools System Redesign

45. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
    March 15, 2004 - We examined adverse occurrences, not adverse events. … Adverse events in surgical patients in Australia. … Proportion of hospital deaths associated with adverse events. … Adverse drug events in hospitalized patients. … The costs of adverse drug events in hospitalized patients.

46. Making Healthcare Safer III | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html
    August 01, 2024 - Harms such as adverse drug events, healthcare-associated infections (HAIs), falls, and obstetric adverse … events are responsible for thousands of deaths and hundreds of thousands of injuries each year. … including medication management, healthcare-associated infections, nursing-sensitive practices, procedural events … 415.4 KB) Harms Due to Anticoagulants (PDF, 2 MB) Harms Due to Diabetic Agents (PDF, 1.6 MB) Reducing Adverse … Drug Events in Older Adults (PDF, 415.7 KB) Harms Due to Opioids (PDF, 2.1 MB) Patient Identification

47. Connecticut Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201806.html
    October 01, 2018 - Connecticut Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools Search All Impact … facility-wide improvements in patient safety culture, which led to an 86 percent decline in serious safety events … questionnaire were part of a comprehensive patient safety program launched in 2013 for measuring preventable adverse … events,” he said. … We’ve found that preventable adverse events resulting in moderate to severe harm or death have dropped

48. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/index.html
    August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … In short, the CANDOR process is a more patient-centered approach that emphasized early disclosure of adverse … events and a more proactive method to achieving an amicable and fair resolution for the patient/family … Interaction—Nurse Module 7: Resolution Resolution Facilitator Notes ( PowerPoint , 757 KB) Adverse … Care Video: Notification of Adverse Event Video: Planning for Meetings with Family Video: Disclosure

49. Grant Final Report: Toward an Optimal Patient Safety Information System (TOPSIS) (pdf file)
    www.ahrq.gov/sites/default/files/2024-04/koss-report.pdf
    January 01, 2024 - events.(4,5) Complete and accurate field data on adverse events across the nation are still scarce … Distribution of Reports of Adverse Events. … Sources of Reports of Adverse Events. … The ways in which hospitals learn about adverse events can impact the way in which events are addressed … and adverse events that occur in their hospital.

50. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - drug events using 247 adverse drug events in 207 hospitalized patients in 2 hospitals in Boston over … adverse events. … events and 8.37 percent for those without potentially preventable adverse medical events. … medical events, and 5.61 percent for those without potentially preventable adverse medical events. … by patients experiencing adverse events.

51. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
    June 01, 2023 - Although the literature has established that patients can identify and reliably report on a range of adverse … substantial aftereffects can persist for many years, elicitation techniques must inquire about the impact of adverse … events that occurred as much as 5 years in the past. … responsibility for eliciting accounts in ways compatible with how patients and families respond after an adverse … Identifying practices that affect the persistence of adverse effects long after a perceived diagnostic

52. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
    November 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention provides a strategy for preventing adverse … events in nursing homes. … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early. … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

53. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
    January 01, 2025 - adverse incidents that occur in the nursing home setting, including falls; adverse drug events or medication … drug events among nursing home residents, researchers found that 42% of all the adverse drug events … This could then be a major deterrent for nursing homes to disclose adverse events. … The epidemiology of adverse and unexpected events in the long-term care setting. … adverse event 2.04 (0.05) Organizational 12 Belief that reporting adverse events have little contribution

54. The Relationship Between Hospital Workload and Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
    January 01, 2024 - Table E2: Adverse events explicitly specified for identification during chart review Adverse event … events and the time of adverse event occurrence. … adverse events (false negative). … We chose to focus on Adverse Drug Events (ADE) as the initial type of adverse events modeled. … Bates, D.W., et al., Evaluation of screening criteria for adverse events in medical patients.

55. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/pfp/methods.html
    December 01, 2017 - Events Associated With Hip Joint Replacements MPSMS Adverse Events Associated With Knee Joint … events for all patients to adverse events for patients with one of the four diagnoses. … Events Associated With Hip Joint Replacements 1.02 3.70 0.28 All Other HACs Adverse Events … Events Associated With Hip Joint Replacements 30,413 32,750,000 0.929 MPSMS Adverse Events … events for all diagnoses to adverse events for the four diagnoses.

56. Final Progress Report: Enhancing the Detection and Management of Adverse Drug Events in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/handler-report.pdf
    January 01, 2024 - Final Progress Report: Enhancing the Detection and Management of Adverse Drug Events in the Nursing Home … Detects and manages adverse drug events………... 1 2 3 4 5 1 2 3 4 5 13. … Detecting adverse drug events using a nursing home specific trigger tool.  … Epidemiology of medication‐related adverse events in nursing homes.  … Incidence and preventability of adverse drug events in nursing homes. 

57. References | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/pfp/hacrate2013-refs.html
    October 01, 2015 - Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Obstetric Adverse Events Abuhamad A, Grobman WA. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.

58. References | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/pfp/interimhac2013-ref.html
    December 01, 2014 - Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Impact of a comprehensive strategy on obstetric adverse events. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.

59. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
    January 01, 2024 - Rates of preventable warfarin-related adverse events were lower in intervention homes, although this … events and potential warfarin-related adverse events. … adverse events, serious or more severe preventable warfarin-related adverse 7 events, and potential … adverse events. … Dementia and the Incidence of Adverse Drug Events in the Nursing Home.

60. Harborview Medical Center Uses AHRQ’s Quality Indicators To Improve Patient Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/202504.html
    June 01, 2025 - A level 1 trauma center and safety net hospital, Harborview uses QIs to review adverse events and integrate … Using QIs has also improved Harborview’s Patient Safety and Adverse Events Composite rating ( PSI 90 … PSIs are a subset of QIs that focus on in-hospital safety issues, specifically for adverse events that