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1. Serious Reportable Adverse Events in Health Care (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
   December 01, 2000 - Serious Reportable Adverse Events in Health Care 339 Serious Reportable Adverse Events in Health … Criteria for including events on the list The core set of adverse events identified by the NQF was … Serious Reportable Adverse Events 343 Table 1. … Serious Reportable Adverse Events 347 Since the NQF promulgated this list of serious reportable events … adverse events with some type of national, standardized system of codes.

2. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/data/infographics/adverse-drug-events.html
   August 01, 2018 - Drug Events Occurring in U.S. … Drug Events Occurring in U.S. … Hospitals Adverse Drug Events Occurring in U.S. … Hospitals (PDF, 1.5 MB) Source:   HCUP Statistical Brief #164: Characteristics of Adverse Drug Events … Drug Events Occurring in U.S.

3. Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/news/newsletters/e-newsletter/899.html
   February 01, 2024 - Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals … [PDF, 9 MB]) Today's Headlines: Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing … Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals Patients with heart … Additional articles featured this week include: Adverse safety events in emergency medical services … Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse events.

4. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
   March 01, 2004 - Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes 245 Surveillance … Methods ICD-9-CM codes suggestive of surgical adverse events An adverse event was considered to be … ICD-9-CM code-identified adverse events confirmed by medical record abstraction Adverse event class … Adverse events related to medical care, Utah: 1995–1999. … ICD-9-CM code-identified adverse events confirmed by medical record Table 2.

5. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
   July 01, 2022 - Researchers of this study tracked a total of 21 adverse events over the study period. … Examples of the events included adverse medication events such as those associated with the use of insulin … Adverse events are often defined as physical or psychological harm caused by a person’s interaction with … Tracking the rates of adverse events is a common way of measuring changes in patient safety. … In the study, researchers examined the rates of adverse events by looking at the raw (observed) rates

6. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/hai/pfp/methods.html
   December 01, 2017 - 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 … 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.

7. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/reports/liability/neumiller.html
   August 01, 2017 - Incidence and preventability of adverse drug events in nursing homes. … Incidence of adverse drug events and potential adverse drug events; implications for prevention: ADE … The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. … National surveillance of emergency department visits for outpatient adverse drug events. … Adverse drug events in ambulatory care. N Engl J Med 2003; 348:1556‑64. 33.

8. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
   April 01, 2004 - Case Definitions (and Guidelines) for Adverse Events Following Immunization Katrin S. … Safety can only be inferred indirectly from the relative absence of multiple, likely adverse events … Case Definitions for Adverse Events After Immunization 91 Global standardization in immunization … Case Definitions for Adverse Events After Immunization 101 23. Rigau-Perez JG, Bonilla GL. … Surveillance of adverse events following immunization.

9. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
   September 01, 2022 - events were occurring in order to prevent them. … This chart review-based surveillance system determines national rates for 21 types of adverse events, … events. … use/misuse, surgical site infections, and other surgical and anesthesia-related adverse events, as well … as obstetric and neonatal adverse events.

10. Module 7: Resolution | Agency for Healthcare Research and Quality
    www.cpsi.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 for … 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

11. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    www.cpsi.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

12. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
    www.cpsi.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

13. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.cpsi.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)) .

14. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - Results: The project generated new epidemiological evidence of patient safety risks and adverse events … The proposed Aims were: Aim 1: To analyze the frequency and determinants of errors and adverse events … Despite the frequency of ambulatory patient safety errors and adverse events, most efforts to study … Second, rare adverse events are challenging to accurately identify. … Adverse drug events in the outpatient setting: an 11-year national analysis.

15. Declines in Hospital-Acquired Conditions (pdf file)
    www.cpsi.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

16. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
    www.cpsi.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

17. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    www.cpsi.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

18. References | Agency for Healthcare Research and Quality
    www.cpsi.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.

19. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
    November 19, 2015 - About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated

20. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Introduction to Adverse Events Slide 23. Immediate Response to an Adverse Event 4 Slide 24. … Introduction to Adverse Events Say: Adverse events occur when a patient is harmed as a result of … Medical providers are committed to caring for their patients; however, adverse events can happen. … The Second Victim: Health Care Workers 7 Say: Adverse events are often system failures. … Organizations need to engage in strategies to address adverse events.