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61. Table 5.A.1. Evidence Table (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-5a-evidence-table.pdf
    January 01, 2014 - Only 4% of the identified adverse events were also identified via incident reports. 3181d8e405.12 … A total of 3,430 AEs were identified. … reports identified 4 ADEs (3.7%). … Nurse reviews identified 93 of 120 events (78%), POA analysis identified 61 events (51%), interviews … identified 22 events (18%), incident reports identified 8 events (7%), and PSI analysis identified

62. Charting diagnostic safety: exploring patient-provider discordance in medical record documentation. | PSNet
    psnet.ahrq.gov/issue/charting-diagnostic-safety-exploring-patient-provider-discordance-medical-record
    April 13, 2022 - In this study, patients identified as at-risk for diagnostic errors were asked to review their most recent … In 467 patients, 51 identified a concern, typically related to communication issues, accuracy of the … Physician chart reviewers identified diagnostic concerns in 31 cases, of which only 11 were also identified

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60052/psn-pdf
    March 18, 2020 - Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective … Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective … https://psnet.ahrq.gov/issue/analysis-pharmacist-identified-medication-related-problems-two-united- … The majority (70%) of medication errors were identified during or before the first inpatient admission … However, the  study also identified that medication errors continue throughout the hospital stay, indicating

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854374/psn-pdf
    October 11, 2023 - Learning from latent safety threats identified during simulation to improve patient safety. … Learning from latent safety threats identified during simulation to improve patient safety. … https://psnet.ahrq.gov/issue/learning-latent-safety-threats-identified-during-simulation-improve-patient … This article describes the classification of 1,318 latent safety threats identified from 232 simulations … https://psnet.ahrq.gov/issue/learning-latent-safety-threats-identified-during-simulation-improve-patient-safety

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/864852/psn-pdf
    March 20, 2024 - Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative … Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative … https://psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized … Of the 26 cases identified by the GTT, 16 were considered part of the patient's disease trajectory or … https://psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative

66. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
    August 01, 2022 - families, and caregivers impacted by harm and to address many of the quality and safety priorities identified … Typically, CANDOR events can be identified via verbal communication to risk management/patient safety … Do: Activity: List de-identified events that have occurred in your organization. … The first part begins 72 hours after a CANDOR event has been identified. … The second part should occur within 30-45 business days after a CANDOR event has been identified.

67. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
    January 01, 2024 - Ninety percent identified themselves as White, 3.2% as Black, 2.5% as Hispanic, and 1.6% as Asian. … Relevant reports were de-identified. … The teams considered the identified failure modes and, using weighted voting techniques, identified … They identified risks associated with temozolomide that were not identified by the capecitabine FMEA … Participants identified a number of improvement opportunities.

68. Common Problems Identified During Peer Review | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/process/grant-app-basics/peerprob.html
    October 01, 2014 - Common Problems Identified During Peer Review Below is a list of many common problems that result

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/863759/psn-pdf
    March 06, 2024 - Clinician responses to disruptive intraoperative behaviour: patterns and norms identified from a multinational … Clinician responses to disruptive intraoperative behaviour: patterns and norms identified from a multinational … //psnet.ahrq.gov/issue/clinician-responses-disruptive-intraoperative-behaviour-patterns-and-norms- identified … https://psnet.ahrq.gov/issue/clinician-responses-disruptive-intraoperative-behaviour-patterns-and-norms-identified … https://psnet.ahrq.gov/issue/clinician-responses-disruptive-intraoperative-behaviour-patterns-and-norms-identified

70. The Relationship Between Hospital Workload and Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
    January 01, 2024 - Adverse drug events and hospital- acquired infections identified by chart review and not identified by … The nurses used a revised CADET tool to document the identified AEs. … not identified by manual chart review. … Of those, 13 were also identified by chart review, and 100 patients were identified to have ADEs that … were not identified by computer surveillance.

71. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
    January 01, 2024 - Results: The HFMEA process identified 40 high-risk failure modes and 75 associated high-risk causes. … decision with rest of care staff C) Caregiver identified and notified 2. … Figure 2 Caregiver identified and notified about potential discharge FMEA Step 4 Hazard Analysis … We identified risks related to lack of communication between care providers in the hospital, between … Additional identified risks included potential lack of knowledge and skills among community-based care

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837589/psn-pdf
    June 29, 2022 - Monitoring preventable adverse events and near misses: number and type identified differ depending on … Monitoring preventable adverse events and near misses: number and type identified differ depending on … https://psnet.ahrq.gov/issue/monitoring-preventable-adverse-events-and-near-misses-number-and-type- identified-differ … Using each of the three methods, this study identified the number and types of near misses and adverse … https://psnet.ahrq.gov/issue/monitoring-preventable-adverse-events-and-near-misses-number-and-type-identified-differ

73. Chipra118-Materials Ii (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA118-Materials_II.pdf
    June 02, 2025 - Eligible Population Numerator: Live-born neonates with a birthweight of less than 2500 grams (as identified … Children identified as having received Level 2 care either via medical record review and/or via revenue … Documentation if child met local criteria for hypothermia and time so identified xi. … Location was identified as a birthing room or equivalent OR 3. … Location was identified as an operating room or equivalent, OR 2.

74. Get Ready | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/getready.html
    October 01, 2017 - Has your hospital identified hospital-specific reasons to change how it manages the prevention of pressure … Has your hospital identified a senior leader who can serve as a champion for the pressure injury prevention … Has your hospital identified a leader for the AHRQ pressure injury prevention effort?   … If yes, have you identified a goal for improvement?   … If yes, have you identified a goal for improvement?  

75. Cannabis-2023-Update-Surv-Rep-3 (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/related_files/cannabis-2023-update-surv-rep-3.pdf
    January 01, 2023 - Figure 1 shows the literature review process that identified the studies. … The list of all studies identified since the 2023 systematic review are in Table 1, with studies identified … Literature flow diagram Note: Numbers in parentheses indicate all records identified up to the 2023 … Numbers in brackets indicate the number of records identified since the systematic review was completed … New studies identified since the 2023 systematic review Search Period Citation Risk of Bias N

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844993/psn-pdf
    February 22, 2023 - Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening … Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening … https://psnet.ahrq.gov/issue/prevalence-undiagnosed-diabetes-identified-novel-electronic-medical-record … https://psnet.ahrq.gov/issue/prevalence-undiagnosed-diabetes-identified-novel-electronic-medical-record-diabetes-screening … https://psnet.ahrq.gov/issue/prevalence-undiagnosed-diabetes-identified-novel-electronic-medical-record-diabetes-screening

77. Sustainability Action Plan | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/assessment-tool.html
    March 01, 2017 - scores for each domain, and make notes on more specific barriers and opportunities for improvement you identified … the likelihood of sustaining areas of the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI that you identified

78. Final Progress Report: Adverse Event-Directed Analysis in Ambulatory Primary Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-10/kennerly-ballard-report.pdf
    January 01, 2024 - Three characteristics of AEs identified in primary care are of particular interest: 1) attribution (to … e) Revision of existing definitions for categorization of identified AEs. … AEs Positive Triggers RN Identified AEs Positive Triggers RN Identified AEs Total 8077 698 … In the 2006 audit, 13.5% of patients had at least one nurse-identified AE. … Adverse events in primary care identified from a risk- management database. J Fam Pract.

79. Environmental Scan - Dissemination and Implementation of Nonsurgical Urinary Incontinence (UI) Treatment for Women in Primary Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/mui/mui-environmental-scan-brief.pdf
    January 01, 2023 - KEY FINDINGS • The updated environmental scan, published in March of 2024, identified 48 articles … This nearly doubled the number of studies identified in the original scan, which was published in October … that evaluated referrals in primary care and other settings for both UI and other conditions were identified … : 48 Representing 27 Studies While additional studies identified in the updated scan partially addressed … Key Areas for Further Study to Improve UI Care Supplemental Search Results Total Articles Identified

80. Living Systematic Review on Cannabis and Other Plant-Based Treatments for Chronic Pain: 2023 Update -- Surveillance Report 4 (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/related_files/cannabis-2023-surv-rep-4.pdf
    January 01, 2023 - Figure 1 shows the literature review process that identified all included studies. … The list of all studies identified since the 2023 systematic review is in Table 1, with the study identified … Literature flow diagram Note: Numbers in parentheses indicate all records identified up to the 2023 … Numbers in brackets indicate the number of records identified since the systematic review was completed … New studies identified since the 2023 systematic review Search Period Citation Risk of Bias N