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81. 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.

82. 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

83. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.html
    August 01, 2022 - to establish an initiative to help States and health care systems test new models of care delivery, adverse … previously collected patient complaint data suggests that patient complaints may be a predictor of adverse … events. … drug events. … that would also be Automatically Compensable Events (ACEx2), a list of 18 events meeting these criteria

84. 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

85. 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.

86. 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

87. 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.

88. 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

89. 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

90. 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.

91. 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

92. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/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

93. 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)) .

94. A | Agency for Healthcare Research and Quality
    www.ahrq.gov/topics/a.html
    September 04, 2025 - Topics Browse A - Z A Access to Care Adverse Drug Events (ADE) Adverse Events

95. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
    September 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Slide 6: On-Time Reports for  Four Adverse Events Four Reports: Pressure Ulcer Prevention. … Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events. … Slide 15: Facilitator Discussion: Value of On-Time Reports Focus on preventing adverse events.

96. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Slide 6: On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer Prevention Pressure … Provide a snapshot at the resident, unit, or facility level for residents at high risk for adverse events … Slide 15: Facilitator Discussion: Value of On-Time Reports Focus on preventing adverse events.

97. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … On-Time Overview 5 October 2017 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … events.

98. On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
    December 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Slide 6: On-Time Reports for Four Adverse Events Available Reports Pressure Ulcer Prevention … Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events. … Slide 15: Facilitator Discussion: Value of On-Time Reports Focus on preventing adverse events.

99. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
    November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … events? … November 2016 On-Time Overview 5 5 On-Time Reports for Four Adverse Events Available Reports: Pressure … Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events November

100. Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-ptsafety.html
     September 01, 2015 - from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.