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61. 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

62. 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

63. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix I Glossary Adverse safety event: a deviation … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … In many events, those not involved tend to believe that they could have predicted the event and therefore … Latent hazard: the hidden problems within health care systems that contribute to adverse events

64. 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.

65. 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 .

66. 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.

67. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/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

68. 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

69. 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.

70. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
    www.ahrq.gov/downloads/pub/advances/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

71. 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

72. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
    January 01, 2024 - Between 19 to 28 percent of patients experience adverse events during care transitions. … These adverse events, which may lead to hospital readmissions, represent an ongoing threat to patient … events. … Building on his efforts to reduce adverse events during care transitions, Dr. … It also will help patients to understand their individualized risks of adverse events during care transitions

73. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
    January 01, 2024 - Previous studies suggest that EDs are a common site of occurrence for adverse events. … Negligent adverse events (defined as adverse events resulting from “care that fell below community standards … ”) were more common in EDs (70.4% of adverse events) than in any other settings. … Because adverse events and negligent adverse events were detected through reviewing charts of hospitalized … events, preventable adverse events combined with critical errors) and independent variables (e.g.,

74. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
    August 01, 2022 - Slide 1 Say: When adverse patient events occur, the patient and their family are looking … events. … Following patient harm events, the patient and/or family might sue the caregiver and/or organization, … When harm occurs, patients often express the desire to protect others from future events. … These metrics include organizational performance relative to adverse events, financial impact, as well

75. 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.

76. 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.

77. 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.

78. 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.  

79. 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.  

80. 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