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61. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
    April 01, 2018 - The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Detecting adverse events using information technology. … Adverse Events in Hospitals: Methods for Identifying Events. … Adverse events among children in Canadian hospitals: The Canadian Paediatric Adverse Events Study. … Adverse events and preventable adverse events in children.

62. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … Do: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. … events.”

63. Executive Summary | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
    September 01, 2020 - The role of language barriers and their impact on adverse events is now receiving greater attention. … Recent research suggests that adverse events that affect limited-English-proficient (LEP) patients are … Common Causes of Adverse Events for LEP and Culturally Diverse Patients Below is a summary of common … Figure C: Types of Physical Harm Experienced From Adverse Events by English-Speaking and LEP Patients … Evidence shows that unaddressed language barriers put patients at high risk for adverse events.

64. AHRQ Researchers Find Link Between Job Flexibility and Healthcare Access and Use | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/818.html
    June 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Study Finds Relationship Between Readmission Rates, Adverse Events in Hospitals . … Study Finds Relationship Between Readmission Rates, Adverse Events in Hospitals Patients with pneumonia … admitted to hospitals with high readmission rates were more likely to experience adverse events, a new

65. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/resources/improve-discharge/index.html
    July 01, 2022 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … Toolkit To Improve Medication Reconciliation Across Care Settings Six New Jersey Hospitals Reduce Adverse … Patient Safety and Team Communication Through Daily Huddles AHRQ PSNet Primer: Medication Errors and Adverse … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety

66. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
    November 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention provides a strategy for preventing adverse … events in nursing homes. … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early. … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

67. AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/making-healthcare-safer/index.html
    July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse … events and associated systemic and contextual factors.

68. 2017Qdr-Patsafchartbook (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
    October 01, 2018 - drug event to warfarin (Adverse drug events) …  Procedure-related events.  Adverse drug events. … events associated with hip joint replacement, adverse events associated with knee joint replacement … events associated with hip joint replacement, adverse events associated with knee joint replacement … Events 30-Day Mortality for Colorectal Surgery Adverse Drug Events Adverse Events With Hypoglycemic

69. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/index.html
    August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home In October 2009, AHRQ launched … Hickson Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor … Bolkan Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital

70. Section 7C (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
    February 02, 2018 - Table VII.C.1 – Distribution of insurance types and adverse … events across sites based on GAPPS study analytic sample (n = 3,151) Insurance n (%) AE rate P-Value … 58.2%) 0.10 <0.001 No Insurance 102 (3.2%) 0.04 0.001 Table VII.C.2 – Analysis of differences in adverse

71. Articulate Word Output (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/primary-prevention-cvd-with-statins.pdf
    May 10, 2018 - Articulate Word Output Primary Prevention of Cardiovascular Disease (CVD) Events with Statins 1 … There is no good reason to use a high- cost brand name statin. 10 Statins: Adverse Effects … The most important adverse effect of statins is myopathy, or muscle pain, which is reported in about … Other hypothesized adverse effects such as memory loss have not been confirmed when they’ve been examined … On the other hand, the adverse effects appear to be relatively independent of CVD risks.

72. Table 7.A (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
    February 02, 2018 - Table VII.A.1 – Distribution of race/ethnicity and adverse … events across sites based on GAPPS study analytic sample (n = 2,834) Race/Ethnicity n (%) AE rate … Hispanic 352 (12.4%) 0.18 <0.001 Other 161 (5.7%) 0.12 0.12 Table VII.A.2 – Analysis of differences in adverse

73. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - A pre-scripted immediate response to events, along with a tightened timeline for event reviews. … event or near miss is the prevention of future adverse events. … When an adverse event occurs, too often, the focus is on an individual's performance and is corrected … If these factors can be identified and modified, the chance of similar events can be reduced. … The systems approach recognizes that all adverse events have multiple contributing factors, many of which

74. Return on Investment Tool (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
    January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

75. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … (PDF, 11.1 MB) Text Description: 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 … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease. … Obstetric events: 3% decrease. Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

76. Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe) | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/sands.html
    August 01, 2017 - adverse events and errors. … Its goals are to (1) proactively identify adverse events, (2) differentiate between injuries caused by … The DA&O approach to adverse events initially did not gain momentum as a risk management practice and … events. … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals. 

77. Table 7B.1 (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
    February 02, 2018 - Table VII.B.1 – Distribution of numbers of Chronic Condition Indicators per patient and adverse … events across sites based on GAPPS study analytic sample (n= 3,442) Chronic Condition Indicators … <0.001 3 or more body systems 125 (3.6%) 0.27 <0.001 Table VII.B.2 – Analysis of differences in adverse

78. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - events and associated systemic and contextual factors. … Table of Contents Adverse Drug Events (ADEs): General Medication Topics ADEs: Harms Due to Anticoagulants … ADEs: Harms Due to Diabetic Agents ADEs: Reducing Adverse Drug Events in Older Adults ADEs: Harms … ) MHS III (2020) Computer Adverse Drug Event Detection and Alerts Summary of Evidence (Not reviewed … Adverse Drug Events Related to Anticoagulants Summary of Evidence Update (Not reviewed) The

79. Changing-System-Facilitator-Guide (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - These are adverse events most likely caused by an antibiotic that he probably did not need. … This four-step approach is incorporated into the Learning From Antibiotic-Associated Adverse Events form … For example, you can obtain baseline data regarding number of adverse events related to antibiotic use … Then compare this to the number of adverse events after your intervention to determine if the intervention … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.

80. AHRQ Safety Program For Long-Term Care: CAUTI
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
    March 01, 2017 - HAIs/CAUTI Long-Term Care Safety Modules Teamwork and Communication | ‹#› 27 Communicating Adverse … Events Adverse event: An injury to a resident caused by medical intervention rather than by the underlying … The mission of frontline care providers is to help and care for residents without harming them, but adverse … events happen  When an adverse event occurs, it can be difficult for a care provider to take ownership … Outcomes Immediate Response to an Adverse Event Next Steps in Responding to an Adverse Event Care