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81. 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.

82. 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).

83. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
    August 24, 2015 - events. … When harm occurs, patients often express the desire to protect others from future events. … event. 11 Measuring Resolution Improvement Organizational performance, relative to adverse events Length … The severity level of adverse events reported. Length of time it takes to disclose the event. … These metrics include organizational performance relative to adverse events, financial impact, as well

84. 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?

85. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/api.html
    February 01, 2017 - Event Investigation and Analysis Guide: Appendix I Adverse safety event: a deviation from … 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

86. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
    June 01, 2023 - References Patient perspectives offer unique information about how diagnosis-related events … enrich clinicians’ understanding of patient and family experience and reduce the harms that follow adverse … diagnostic events. … Although patient and family conceptions of adverse events do not always conform to clinical definitions … diagnostic errors, it is important to identify and understand the broader scope of patient-defined adverse

87. 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.

88. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16463-Gurwitz-report.pdf
    January 01, 2011 - 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.

89. Results | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/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

90. 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)) .

91. 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.

92. Final Progress Report: Conference on Medical Error Communication and Dispute Resolution (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/liebman-hyman-report.pdf
    January 01, 2024 - of individuals from various disciplines to share information about disclosure of medical errors and adverse … events, use of alternative dispute resolution rather than litigation to resolve medical malpractice … events and from the resolution of a medical malpractice claim through mediation. … Presenters explored the benefits and risks of apology and disclosure after an adverse event or medical … events.

93. Making Healthcare Safer for Older, Vulnerable Patients | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/grantee-profiles/grtprofile-gurwitz.html
    September 01, 2019 - Drug Events . … Many of these adverse drug events (ADEs) are thought to be preventable.  … He recently completed an AHRQ-funded study that identified the incidence and type of adverse events that … The observational study, published in JAMA Internal Medicine in July 2019, found that adverse events … Pressure ulcers, skin tears, and falls made up half of the adverse events; healthcare-acquired infections

94. 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?        

95. 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.

96. Declines in Hospital-Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019-updated.pdf
    January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections -37% … Falls -5% Obstetric Adverse Events -3% Pressure Ulcers Surgical Site Infections Ventilator

97. Declines in Hospital-Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
    January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections -37% … Falls -5% Obstetric Adverse Events -3% Pressure Ulcers Surgical Site Infections Ventilator

98. Declines in Hospital-Acquired Conditions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
    January 01, 2019 - in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,500 deaths and saved $7.7 billion between 2014 … Adverse Drug Events -28% CAUTI* -5% CLABSI+ -6% Clostridioides difficile Infections … -37% Falls -5% Obstetric Adverse Events -5% Pressure Ulcers 6% Surgical Site

99. 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

100. 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