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81. 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

82. 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?

83. 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?        

84. 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

85. 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.

86. 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

87. Final Progress Report: Improving Patient Safety and Disease Management While on Contact Isolation (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/morgan-report.pdf
    January 01, 2024 - Results: We found no increase in adverse events related to patient isolation. … Key Words: Isolation, MRSA, Contact Precautions, Adverse events Purpose: (Objectives of study) This … A prospective matched cohort was utilized to assess adverse events (Aim 1.2), measures of depression … The effect of universal glove and gown use on adverse events in intensive care unit patients. … The effect of contact precautions on frequency of hospital adverse events.

88. Final Progress Report: Improving the safety of pediatric tracheal intubation in ICUs with apneic oxygenation and video laryngoscopes (pdf file)
    www.ahrq.gov/sites/default/files/2025-06/nishisaki3-report.pdf
    January 01, 2025 - These pediatric-specific features increase risks and adverse events associated with TI procedures. … tracheal intubation associated events were reported in 5.7% of children without intervention from … events and severe events. … Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events … Hemodynamic Events.

89. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
    June 04, 2008 - In particular, the exchange of device-related safety information and reports on adverse events with … Given that the FDA does not have unlimited resources to investigate and address adverse events with … adverse events and situations indicating the potential for harm related to these devices. … Obstacles to reporting adverse events to the FDA were identified as well. … KidNet’s focus is on identifying and reporting all medical device-related adverse events that occur

90. 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.

91. Mod02-Business-Case-Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/mod02-business-case-worksheet.pdf
    April 01, 2016 - – 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 … event • Number of adverse events reported >24 hours after occurrence – Severity level of adverse … (Track, analyze, and compare adverse events managed pre implementation, then follow up with additional … Determine a return on investment that ties to reduced adverse events. 4 – Building the Business Case

92. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
    July 01, 2020 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers/pressure … For example, measured adverse drug events continued to drop from 2014 to 2017, while measured pressure … Urinary Tract Infections Adverse Drug Events 99 92 88 86 https://www.ahrq.gov/sites/default/files … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … To estimate the rate of adverse events for each of the 21 HACs for all patients for which the MPSMS

93. 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.

94. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
    May 01, 2017 - Summary of impact on maternal and neonatal adverse events for L&D units submitting adverse event data … Impact on adverse events. … Events Absolute changes in adverse events from baseline to 10 months were measured using hospital … Because most of the adverse events monitored are rare, absolute changes in these events can result in … The measures used for adverse events were limited by the fact that most adverse events are rare, may

95. I. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/hotline/intro1.html
    May 01, 2016 - Importantly, none of these events were documented in the hospital’s adverse event reporting systems. … Two-thirds of the adverse events were detected by patient interview alone, demonstrating that patients … could identify adverse events of which the hospital was unaware. … Weingart and colleagues 29 found that 73 percent of adverse events occurring in primary care practices … The collection of data was to focus on adverse events, near-miss events, and unsafe conditions as perceived

96. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Slide 6: On-Time Reports Being Developed for Four Adverse Events Four Reports: Pressure Ulcer … Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events. … How the facility investigates adverse events.

97. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/factraining_slides.pptx
    December 01, 2014 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … December 2014 On-Time Overview 5 5 On-Time Reports Being Developed for Four Adverse Events Four Reports … for prevention discussion with On-Time reports How the facility investigates adverse events Talk to

98. Acute Care Learning From Defects
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
    November 01, 2019 - Events Adverse event: Patient develops acute kidney injury Learning from antibiotic-associated adverse … events: What happened? … 10 Antibiotic-related adverse events are events that either caused harm or had the potential to cause … Events Five categories of factors that contribute to adverse events Patient factors are related to the … events related to antibiotics should be evaluated to determine areas for improvement.

99. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
    August 01, 2022 - events. … events and promote better care for patients through candid, caring communication in the wake of an adverse … events from happening in the future. … It also emphasizes the organization's commitment to improve the reporting and monitoring of adverse events … event (see Adverse Event (Reasonable Care) and Adverse Event (Unreasonable Care)) .

100. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
     January 01, 2024 - Primary outcomes included teamwork climate and adverse events. … to detect adverse events. … We calculated estimated proportions of occurrence of adverse events. … one or more adverse events. … Exploring the causes of adverse events in NHS hospital practice. J R Soc Med.