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361. Disclosure Checklist | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.   … Explain your role in the event to the patient/family; avoid blaming others or "the system" for the event … Consider ways to involve patients in post-event learning.  

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60749/psn-pdf
     August 05, 2020 - Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". … Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients- never-event … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event … psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event

363. Module 7: Resolution | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
     August 01, 2022 - However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Some organizations choose to involve patients/families in some manner in the event analysis process. … Potential future injuries that may result from the adverse event.

364. Module 7: Resolution | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
     August 01, 2022 - However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Some organizations choose to involve patients/families in some manner in the event analysis process. … Potential future injuries that may result from the adverse event.

365. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
     www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
     April 01, 2018 - Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) Obese, … Event 182 (0.2) Fail to administer indicated antibiotics Event 543 (0.0325) SSI risk for … during home care Event 433 (0.05) Patient has organism at postoperative visit Event 543 … Event 30 (0.125) Fail to prepare skin appropriately Event 543 (0.0325) SSI risk for obese … Event 450 (0.293) Obese, but not diabetic, patient (30Event 642 (0.2) Fail

366. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
     April 01, 2018 - Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) Obese, … Event 182 (0.2) Fail to administer indicated antibiotics Event 543 (0.0325) SSI risk for … during home care Event 433 (0.05) Patient has organism at postoperative visit Event 543 … Event 30 (0.125) Fail to prepare skin appropriately Event 543 (0.0325) SSI risk for obese … Event 450 (0.293) Obese, but not diabetic, patient (30Event 642 (0.2) Fail

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42822/psn-pdf
     December 18, 2013 - Automated adverse event detection collaborative: electronic adverse event identification, classification … Automated adverse event detection collaborative: electronic adverse event identification, classification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification … https://psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43192/psn-pdf
     December 15, 2014 - Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling … Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates-does-it-change … https://psnet.ahrq.gov/issue/using-estimated-true-safety-event-rates-versus-flagged-safety-event-rates-does-it-change

369. Context/Flow Specifications for the Overall CAPI Instrument MEPS–Household Component: Panel 20 (2015-2016)( Consolidated Instrument
     staging-meps.ahrq.gov/survey_comp/overall_p20.shtml
     Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and Flat … (OP) Section including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is

370. MEPS Context/Flow Specifications for the Overall CAPI Instrument - Panel 14 (2009-2010)
     staging-meps.ahrq.gov/survey_comp/overall_p14.shtml
     endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}} BEGINLOOP … If {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment

371. MEPS Context/Flow Specifications for the Overall CAPI Instrument - Panel 15 (2010-2011)
     staging-meps.ahrq.gov/survey_comp/overall_p15.shtml
     endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP … If {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment

372. MEPS Context/Flow Specifications for the Overall CAPI Instrument - Panel 13 (2008-2009)
     meps.ahrq.gov/survey_comp/overall_p13.shtml
     August 01, 2009 - endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP … If {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment

373. MEPS Context/Flow Specifications for the Overall CAPI Instrument - Panel 14 (2009-2010)
     meps.ahrq.gov/survey_comp/overall_p14.shtml
     September 01, 2010 - endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed}} BEGINLOOP … If {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment

374. MEPS Context/Flow Specifications for the Overall CAPI Instrument - Panel 15 (2010-2011)
     meps.ahrq.gov/survey_comp/overall_p15.shtml
     October 01, 2011 - endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for … each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP … If {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment

375. MEPS Context/Flow Specifications for the Overall CAPI Instrument MEPS-HC: Panel 16 (2011-2012)
     meps.ahrq.gov/survey_comp/overall_p16.shtml
     November 01, 2012 - endif Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … } BEGINLOOP Ask Event-Driver (ED) Section [including... … Context: PERSON-EVENT LOOP_03 for each PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event … remains to be processed} BEGINLOOP If {event-type is hospital-stay} Ask Hospital-Stay (HS … ) Section including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type

376. MEPS Context/Flow Specifications for the Overall CAPI Instrument MEPS-HC: Panel 17 (2012-2013)
     meps.ahrq.gov/survey_comp/overall_p17.shtml
     December 01, 2013 - Ask Calendar (CA) Section and Summary of Health Care Events Ask Provider-Probes (PP) , Event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is outpatient}

377. MEPS Context/Flow Specifications for the Overall CAPI Instrument MEPS-HC: Panel 18 (2013-2014) Consolidated Instrument
     meps.ahrq.gov/survey_comp/overall_p18.shtml
     Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is outpatient

378. MEPS Context/Flow Specifications for the Overall CAPI Instrument MEPS-HC: Panel 19 (2014-2015) Consolidated Instrument
     meps.ahrq.gov/survey_comp/overall_p19.shtml
     Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and … including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is outpatient}

379. Context/Flow Specifications for the Overall CAPI Instrument MEPS–Household Component: Panel 20 (2015-2016)( Consolidated Instrument
     meps.ahrq.gov/survey_comp/overall_p20.shtml
     Person LOOP_02 for each PERSON on RU-Members-Roster WHERE {PERSON continues to have an unprocessed event … } BEGINLOOP Ask Event-Driver (ED) Section [including… Context: PERSON-EVENT LOOP_03 for each … PERSON-EVENT on Person’s-Medical-Events-Roster WHERE {event remains to be processed} BEGINLOOP If … {event-type is hospital-stay} Ask Hospital-Stay (HS) Section including Charge/Payment (CP) and Flat … (OP) Section including Charge/Payment (CP) and Flat Fee (FF) Sections endif If {event-type is

380. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - These event types drive the collection of information germane to a specific event. … as a near-miss or “serious event”; the clinical event type according to the PA-PSRS taxonomy used in … PA-PSRS; the procedure involved; how the event was discovered; the disposition of the event; and the … 75.5 Date of admission 37.9 Type (near-miss or serious event) 37.6 How was event discovered 37.6 … Event type (modified UHC taxonomy) 37.6 Disposition of event 37.6 Procedure error: Procedure 30.0