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1. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
   www.monahrq.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.

2. Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals | Agency for Healthcare Research and Quality
   www.monahrq.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.

3. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
   www.monahrq.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.

4. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
   www.monahrq.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

5. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
   www.monahrq.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.

6. Module 7: Resolution | Agency for Healthcare Research and Quality
   www.monahrq.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

7. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
   www.monahrq.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.

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

9. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.monahrq.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)) .

10. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.monahrq.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.

11. Table 5.A.1. Evidence Table (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - events, including adverse drug events (ADEs). … adverse events, including 256 ADEs. The 2010;11(5):568-578. … The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in … Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study … Detecting Adverse Events Using Information Technology.

12. Declines in Hospital-Acquired Conditions (pdf file)
    www.monahrq.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

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

14. References | Agency for Healthcare Research and Quality
    www.monahrq.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.

15. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.monahrq.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.

16. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
    www.monahrq.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

17. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.monahrq.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.

18. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
    September 01, 2020 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: Systems … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Types of Physical Harm Experienced From Adverse Events by English Speaking and LeP Patients. … Common Causes: Adverse Events for LEP Culturally Diverse Patients Use of Family Members/Friends or … Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care .

19. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.monahrq.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

20. Appendix | Agency for Healthcare Research and Quality
    www.monahrq.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