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61. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
    September 01, 2024 - A notable example is the recent release of  Adverse Events Among In-Hospital Medicare Patients in 2021 … The QSRS is a new one-of-a-kind national repository that includes data on 41 types of adverse events … event per hospital stay, with 83.6 adverse events per 1,000 discharges. … These rates improved in 2022, decreasing to 6.2 percent of patients and 71.1 adverse events per 1,000 … In both 2021 and 2022, the three most common individual adverse events for populations with sufficient

62. Dashboard Information | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/info.html
    June 01, 2019 - data that follow the Common Formats for Event Reporting – Hospital Version (CFER-H) definitions of Adverse … Events, i.e., the Common Formats Event Descriptions. … There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific … modules for specific types of adverse events that are common. … well as provides other information relevant to all events (e.g., harm).

63. Vaccine Adverse Event Reporting System Reporting Form | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/vaccine-adverse-event-reporting.html
    August 01, 2022 - Vaccine Adverse Event Reporting System Reporting Form Resource: Vaccine Adverse Event Reporting … Reporting Form This webpage hosts a writable PDF form that provides instructions for reporting a vaccine adverse

64. Implementation Guide for the CANDOR Process: Appendix A | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/impguide/apa.html
    August 01, 2022 - Analyze the organization's frequency of adverse events and malpractice claims to support the rationale … Discuss efforts to improve communication and response to adverse events to date, including the clinical … event: Number of adverse events reported >24 hours after occurrence Severity level of … adverse events reported. … Determine a return on investment that ties to reduced adverse events.  

65. Building the Business Case for CANDOR Worksheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
    August 01, 2022 - Analyze the organization's frequency of adverse events and malpractice claims to support the rationale … Discuss efforts to improve communication and response to adverse events to date, including the clinical … event: Number of adverse events reported >24 hours after occurrence Severity level of … adverse events reported. … Determine a return on investment that ties to reduced adverse events.  

66. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
    September 01, 2014 - Events Associated With Hip Joint Replacements MPSMS Adverse Events Associated With Knee Joint Replacements … 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 Associated … Events Associated With Hip Joint Replacements 30,413 32,750,000 0.929 MPSMS Adverse Events Associated … events for all diagnoses to adverse events for the four diagnoses.

67. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
    July 01, 2004 - This system is immense in scope and provides national rates of adverse events by employing explicit … adverse events beyond the list of MPSMS topics. … Adverse event (a list of adverse events to be examined for each measure). … episode,2 the MPSMS only has the capacity to identify rates for select adverse events. … Thus, the five criteria for selecting adverse medical events were— • the adverse event can be found

68. VI. Summary and Conclusions | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
    May 01, 2016 - What was known after two decades of prior research is that adverse events, errors, and even near-miss … events can be identified, a nomenclature can be created to structure and catalog reports of such events … When adverse event reporting systems were first built, they did not receive many reports.  … Overall, the number of reports received was disappointing, given the potential reservoir of adverse events … Classification of events by type, severity, and contributing factors.

69. Table 5.A.1. Evidence Table (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - events, including adverse drug events (ADEs). … adverse events, including 256 ADEs. The 2010;11(5):568-578. … The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in … Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study … Detecting Adverse Events Using Information Technology.

70. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events? … Identification and Analysis of Actual and Potential Adverse Events: Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events? … Is an attempt made to disclose within the first 24 hours following an adverse event?

71. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
    January 01, 2024 - events. 2) Assessment of the epidemiology of medication errors and adverse drug events in the outpatient … Key Words: Surveillance and reporting of adverse events; adverse drug events in ambulatory pediatrics … adverse warfarin-related events were identified. … Bates DW, Cullen D, Laird N, et al: Incidence of adverse drug events and potential adverse drug events … Adverse drug events in ambulatory care.

72. Final Progress Report: Interactive HIT to promote ambulatory safety among vulnerable diabetes patients (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/sarkar-report.pdf
    January 01, 2024 - PURPOSE The objective of this study was to characterize adverse events and potential adverse events … We hypothesized that diabetes patients will experience adverse events and potential adverse events, … Discussion We detected adverse events and potential adverse events in the course of conducting an automated … Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. … Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

73. Final Progress Report: Risk and Recovery in Complex Environments: Labor and Delivery as a Model (pdf file)
    www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
    January 01, 2025 - Despite efforts to provide safe, effective care, adverse events still occur. … Our current understanding of the nature of medical adverse events, and our ability to develop durable … This tool uses computer-based modeling and simulation to estimate the likelihood of adverse events, … events in complex clinical systems, including how risk varies across time and how adverse events evolve …  What makes a case most vulnerable to adverse events?

74. Results | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/pfp/haccost2017-results.html
    November 01, 2017 - events included postpartum hemorrhage, preeclampsia/eclampsia, and anesthesia-related adverse events … adverse events as the end point. … events and the risk of death among women experiencing maternal adverse events. … events: 37.1 percent (2011-2013 data). 58 We included the following conditions as the adverse events … events, we estimated the annual number of inpatient deaths due to maternal adverse events in the United

75. Preface | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/preface.html
    May 01, 2016 - and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events … demonstrated the feasibility and promise of collecting information from health care professionals about adverse … data about concerns that patients have about the safety of their health care, including errors and adverse … events.

76. Declines in Hospital Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
    June 02, 2025 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 8,000 deaths and saved $2.9 billion between 2014 … Adverse Drug Events CAUTI* *CAUTI - Catheter-Associated Urinary Tract Infections CLABSI+ Clostridium … difficile Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse … Events Pressure Ulcers Surgical Site Infections Ventilator- Associated Pneumonias 0% (Post-op

77. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Is there a clear process for communication among staff in response to adverse events?         … Identification and Analysis of Actual and Potential Adverse Events Is there a process in place … for identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions?   … Do staff have access to a system for reporting adverse events?         … Is an attempt made to disclose within the first 24 hours following an adverse event?        

78. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
    April 01, 2025 - events in hospitalized patients.  … events .   … 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. … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses

79. About the Toolkit Development | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
    July 01, 2023 - Background Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse … that between 2004 and 2014, poor communication was a root cause of 48 percent of sentinel maternal events … and 70 percent of sentinel neonatal events. … inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk of adverse … events on L&D units.

80. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
    January 01, 2025 - Key Words: adverse events, emergency department, trigger tool 3. … Triggers associated with adverse events on bivariate analysis Trigger Pop. Freq. … Adverse events related to emergency department care: a systematic review. … A trigger tool to identify adverse events in the intensive care unit. … The incidence and nature of in-hospital adverse events: a systematic review.