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21. Appendix | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/pfp/hacrate2013-appendix.html
    October 01, 2015 - 2013) Femoral Artery Puncture for Catheter Angiographic Procedures 59,000 1.8 MPSMS (2013) Adverse … Events Associated With Hip Joint Replacements 21,000 0.63 MPSMS (2013) Adverse Events Associated … in Measured HACs c Projected Cost Savings in 2013 d Projected Reductions in Deaths in 2013 e Adverse … $149,600,000 1,628 Falls 260,000 240,000 20,000 8% $144,680,000 1' 100 Obstetric Adverse … 50% 25% 10,000 $17,000 Falls 200,000 25% 50% 12.5% 25,000 $7,234 Obstetric Adverse

22. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 17: Engaging After Adverse Events Say: Adverse events occur when a patient is harmed as a … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 22: The Second Victim: Health Care Workers Say: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … Organizations need to engage in strategies to address adverse events.

23. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/index.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … events and a more proactive method to achieving an amicable and fair resolution for the patient/family … Care Video: Notification of Adverse Event Video: Planning for Meetings with Family Video: Disclosure

24. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - 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 … Preliminary 2017 2019 Goal (20% Reduction of each HAC) Adverse Drug Events 33.7 30.0 27.1 … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … Due to changes in how some conditions and adverse events are described in ICD-9 and ICD-10, the data

25. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
    January 01, 2016 - infections, adverse drug events, and injuries due to procedures, as well as pressure ulcers and falls … For example, measured adverse drug events continued to drop from 2014 to 2016, while measured pressure … Infections (CLABSI) Clostridium difficile Infections Falls Obstetric Adverse Events Pressure Ulcers … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS, including those in the Surgical … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number

26. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
    June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated

27. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … Falls Obstetric Adverse Events Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated

28. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
    July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Slide 17: Engaging After Adverse Events An adverse event is an injury to a patient caused by medical … events happen. … Organizations should be prepared to respond and communicate proactively when adverse events occur.

29. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    www.cpsi.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?

30. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    www.cpsi.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?        

31. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/pfp/hacrate2011-12.html
    January 01, 2018 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for special … Normalized to 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharges Adverse … 17,000 0.51 Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events

32. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
    July 01, 2022 - o How many and what type of adverse events occurred by specific vaccine brand. … This is important because if you are seeing increased adverse events related to a specific vaccine … This is important because if you are seeing increased adverse events related to a specific vaccine administrator … An additional pie chart (Figure 18) illustrates Resident or Staff Adverse Events by Manufacturer. … Figure 18 – Example Adverse Events pie chart Figure 17 - Example Vaccination Status To-Date pie chart

33. AHRQ Views Blog: At the American Society of Health Economists Conference, AHRQ Highlights Its Deep Dive Into COVID-19 | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/news/newsletters/e-newsletter/868.html
    June 01, 2023 - Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Did Not Adverse tracheal intubation-associated events—unwanted events that occur as a result of the … tracheal intubation-associated events. … events.

34. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … their institutions include how to: Engage patients and families in disclosure communication following adverse … events. … Implement a Care for the Caregiver program for providers involved in adverse events. … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

35. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … Events Associated With Hip Joint Replacements 16,000 0.49 MPSMS (2015) Adverse Events Associated … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented

36. Data Resources | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/data/resources/index.html
    April 29, 2024 - Data Resource Name Search   Filter by Topic Access to Care (4) Adverse … Events (1) Ambulatory (2) By Payer (2) By State (3) Children (3) Children (1) … HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about adverse … events and patient safety-related events in U.S. hospitals. … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries

37. Pf-Engagement-Facilitator-Guide (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care. … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 21 SAY: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … Organizations need to engage in strategies to address adverse events.

38. AHRQ Tools To Reduce Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/hai/hac/tools.html
    March 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … To reduce these HACs and other adverse events in hospitals, frontline clinicians and others use many … Antibiotic use:  Toolkit To Improve Antibiotic Use in Acute Care Hospitals Adverse drug events: Medications … ICUs Medical devices: Toolkit for Decolonization of Non-ICU Patients With Devices Obstetrical adverse … events: Toolkit for Improving Perinatal Safety Pressure ulcers: Preventing Pressure Ulcers in Hospitals

39. Staff-Safety-Assessment (doc file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/staff-safety-assessment.docx
    June 01, 2021 - Safety Assessment PURPOSE OF THIS FORM: To discuss issues that may result in antibiotic-associated adverse … events or have the potential to cause adverse events that could negatively impact patient safety.

40. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
    May 01, 2017 - Events An adverse event is an injury to a patient caused by medical intervention rather than by the … The mission of health care providers is to help and care for patients without harming them, but adverse … events happen. … Prompt, compassionate, and honest communication with the patient and family after an adverse event is … Organizations should be prepared to respond and communicate proactively when adverse events occur.