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  1. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/15818-Fairbanks-draft-1.pdf
    September 08, 2008 - Specific Aim 2 Evaluate the impact of the EPh Program Hypothesis: The overall event (adverse drug event … If an event or potential event was identified, the case was forwarded to the Case Review Committee. … The event rate was calculated based on number of patients who experienced an event per total number … Thus, if a single patient had two events, they would only count as one event case. … If an event or potential event was identified, the case was forwarded to the Case Review Committee.
  2. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
    September 01, 2017 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … at high risk or had a recent change in risk, would we do things differently to intervene before the event … These questions explore what the facility does to screen for risk of an adverse event. … Discussion questions are tailored to the On-Time adverse event being addressed. … The menu includes meetings directly related to the adverse event of interest, but additional uses of
  3. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20131008_cg/1_Carla_Zema_Intro_slides_1-23.pdf
    October 08, 2013 - Accessing Event Materials To access the event materials and resources, click on the “Resources” icon … Consider in Selection Today’s Speakers To Ask a Question Accessing Presentations Accessing Event
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/reduce/4-things.pdf
    March 01, 2017 - Urinary Tract Infection (UTI) Event for Long-term Care Facilities. … epididymis, or prostate ■ Pus around the catheter * See CDC's January 2016 "Urinary Tract Infection (UTI) Event
  5. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-2-attachment-6.pdf
    January 17, 2017 - during continuous enrollment period Anchor Date Date of ADHD diagnosis at the physician visit Event … patients, identify all assessment services (see Table 2) with an ADHD diagnosis code at the anchor event
  6. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
    November 01, 2017 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … at high risk or had a recent change in risk, would we do things differently to intervene before the event … These questions explore what the facility does to screen for risk of an adverse event. … Discussion questions are tailored to the On-Time adverse event of interest. … The menu includes meetings directly related to the adverse event of interest, but additional uses of
  7. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
    November 06, 2017 -  Nursing home staff generally do a good job of investigating and following up after an adverse event … to figure out what happened when that resident fell or how that pressure ulcer developed, or what event … high risk or had a recent change in risk, would we do things differently to intervene before the event … These questions explore what the facility does to screen for risk of an adverse event. … Discussion questions are tailored to the On-Time adverse event of interest.
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
    June 11, 2003 - The new “Culture of Safety” led to a paradigm shift in assessing an individual’s performance, event … Alternatively, the information on the event can still be turned in via a hospital form or written out … submitted by a means other than direct computer entry, the patient safety specialist will input the event … Occurrence screen reporting flow diagram Adverse Event or Near Miss Identified Verbal report or form … given to Patient Safety Specialist Event is inputted into database Staff willl enter event into system
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
    April 28, 2008 - non-Federal hospitals, calculated risk-adjusted PSI rates, and compared the likelihood of incurring a PSI event … In non-Federal hospitals, likelihood of a PSI event was higher in major teaching hospitals for decubitus … The AHRQ PSIs are based on the Institute of Medicine (IOM) definition of an adverse event: “Injury … The Harvard Medical Practice Study, using chart-abstracted data, found lower adverse event rates in … We then tested our hypotheses concerning a patient’s likelihood of experiencing a PSI event in major
  10. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/1_dale_shaller_intro.pdf
    October 22, 2014 - Question 7 www.cahps.ahrq.gov Accessing Presentations 8 www.cahps.ahrq.gov Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials Rising Importance of CG-CAHPS
  11. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160315/susan-edgman-levitan-intro-slides.pdf
    March 15, 2016 - Ask a Question 6 www.cahps.ahrq.gov Accessing Presentations 7 www.cahps.ahrq.gov Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials CAHPS Ambulatory Care Improvement
  12. www.ahrq.gov/patient-safety/capacity/candor/videos/physicians.html
    February 01, 2017 - demonstrates an example of emotional support provided for the physician caregiver after an adverse event
  13. www.ahrq.gov/patient-safety/capacity/candor/videos/nurses.html
    February 01, 2017 - video demonstrates an example of emotional support provided for the nurse caregiver after an adverse event
  14. www.ahrq.gov/patient-safety/resources/liability/silence.html
    August 01, 2017 - Doing a thorough event investigation and analysis, or root cause analysis, is an important step in the … hour-care provided while the patient is in the medical setting. 4 Third, taking responsibility for the event … adverse events, continuous communication with patients and families throughout the disclosure process, event … Disclosure is not an event, it is a process, and it does not end until the patient or family says it
  15. www.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - Doing a thorough event investigation and analysis, or root cause analysis, is an important step in the … hour-care provided while the patient is in the medical setting. 4 Third, taking responsibility for the event … adverse events, continuous communication with patients and families throughout the disclosure process, event … Disclosure is not an event, it is a process, and it does not end until the patient or family says it
  16. www.ahrq.gov/news/newsroom/case-studies/201620.html
    February 01, 2017 - "Our goal is to get with the patients and families within 60 minutes of an event," explained Linda Ubaldi … "All we know is an event has happened; we don’t know how or why.
  17. www.ahrq.gov/hai/cauti-tools/impl-guide/index.html
    October 01, 2015 - CAUTI Event Report Template Appendix P. … CAUTI Event Report Template ( Word , 1.6 MB) Appendix P.
  18. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160413/edgman-levitan-intro.pdf
    April 13, 2016 - Question 7 www.cahps.ahrq.gov Accessing Presentations 8 www.cahps.ahrq.gov Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials CAHPS Ambulatory Care Improvement
  19. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-shaller-intro.pdf
    January 01, 2017 - Ask a Question 9 www.ahrq.gov/cahps Accessing Presentations 10 www.ahrq.gov/cahps Accessing Event … To Ask a Question Accessing Presentations Accessing Event Materials First Polling Question
  20. www.ahrq.gov/patient-safety/reports/hotline/implement3.html
    May 01, 2016 - of protocols for processing patient and caregiver reports and for identifying any matching adverse event … Both organizations have a history of hospital-based adverse event and complaint reporting systems that … Both encourage adverse event reporting by staff and have internal mechanisms for staff to report incidents … During the first year of the implementation phase (2013–2104), changes in the patient event reporting … outreach and marketing strategy did not work, or that they were having trouble with the Web page or event

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