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21. References | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

22. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.qualitymeasures.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 .

23. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

24. Antibiotic Side Effects (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-side-effects.pdf
    June 01, 2021 - Antibiotic Side Effects Risk of antibiotic side effects and adverse reactions • Antibiotic use is … events are one of the most common reasons for emergency department (ED) visits for drug-related adverse … events • 1 in 1,000 antibiotic prescriptions leads to an ED visit for an adverse event. … Common side effects and adverse reactions • Gastrointestinal disturbances (such as diarrhea) occur … reactions Common side effects and adverse reactions Potential adverse reactions and drug-drug interactions

25. Appendix | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

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

27. Project Overview: Designing Consumer Reporting Systems for Patient Safety Events | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
    October 01, 2014 - their family members are in a unique position to identify gaps in care that may have contributed to adverse … events. … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … events. … events.

28. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

29. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    www.qualitymeasures.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

30. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    www.qualitymeasures.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

31. Patient and Family Engagement for Perinatal Safety | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

32. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
    July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview Advancing Excellence … more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … events. … view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse … events.

33. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
    www.qualitymeasures.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

34. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.qualitymeasures.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

35. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable … However, the role of language barriers and its impact on adverse events is less well documented. … The one hospital that stratified their adverse event data by language found clusters of adverse events … Common Causes of Adverse Events for LEP and Culturally Diverse Patients In addition to gathering the

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

37. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.qualitymeasures.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

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

39. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

40. Dashboard Information | Agency for Healthcare Research and Quality
    www.qualitymeasures.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. … modules for specific types of adverse events that are common. … The Generic module allows classification of all events as Incident, Near miss, or Unsafe condition as … well as provides other information relevant to all events (e.g., harm).