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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
January 01, 2024 - Introduction
Introduction-Generic Patient Safety Concern
The tables in this workbook present generic data on Patient Safety Concerns submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2023. The tables include distributions of events and…
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www.ahrq.gov/ncepcr/reports/2024-annual-report/profile-p1-barreto.html
April 01, 2024 - Incidence of Serum Creatinine Monitoring and Outpatient Visit Follow-Up among Acute Kidney Injury Survivors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
March 01, 2004 - Identifying Barriers to the Success of a Reporting System
167
Identifying Barriers to the Success
of a Reporting System
Michelle L. Harper, Robert L. Helmreich
Abstract
Spurred by a controversial report from the Institute of Medicine on the prevalence
of medical error, To Err Is Human, the medical profe…
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www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-rationale.html
September 01, 2013 - negligible rate of skin reactions (<1 percent) from CHG use; two other large scale studies reported the incidence
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www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
January 01, 2024 - The “irregularly regular” nature of the
incidence of error further complicates this. … regression was used to investigate associations between hospital and
patient characteristics and the incidence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
January 01, 2003 - * Adjusted for selection of the verification sample
Advances in Patient Safety: Vol. 2
124
Incidence … Most current patient safety reporting systems focus on
incidence of medical error or negligence. … Incidence of
adverse events and negligence in hospitalized patients:
results of the Harvard Medical … Incidence
and types of adverse events and negligent care in Utah
and Colorado.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
January 01, 2004 - morbidity and mortality, studies have shown that prophylactic beta-blocker
therapy can reduce the incidence … with the administration of
intravenous (IV) beta-blocker, other studies have reported an increased incidence … of bradycardia and hypotension.24
Providers also expressed concern regarding the incidence of adverse … The effect
of an infusion of esmolol on the incidence of
myocardial ischaemia during tracheal extubation
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Learning From Defects Tool - Example
ICU & Non-ICU
Problem statement: Healthcare organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that future patients will be harmed.
What is a defect? A defect is any cli…
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www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
January 01, 2024 - Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED)
Principal Investigator: Hall, Kendall K. 7P20HS017111-02
FINAL REPORT
Evaluation of Risk by Active Surveillance in the Emergency Department
(ERASED)
Principal Investigator: Kendall K. Hall, MD, MS (University of …
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www.ahrq.gov/sites/default/files/2024-02/wei-report.pdf
January 01, 2024 - Of the cohort, 6,176 patients developed ORAEs --- i.e., cases --- yielding an
incidence rate of 7.17 … analysis for Aim 1 was restricted to the 3,103 cases that were matched to 3,103
controls selected by incidence
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
June 01, 2023 - The incidence of diagnostic error was 5.6 percent, with the most common errors related to radiology/laboratory
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www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html
January 01, 2017 - Reduce the incidence and duration of delirium in the intensive care unit (ICU) setting. … Delirium "incidence" static; delirium duration may be better metric.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Learn From Defects Tool
AHRQ Safety Program for Surgery
Learn From Defects Tool – Perioperative Setting
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall.
Problem statem…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool—Sample
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include i…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
August 01, 2025 - a publication
from this project assessed the scalability and impact of On-Time on pressure
injury incidence … all 49 CTIs video-recorded before training
showed breaks in sterile technique, and there was a 15% incidence … After training, 53 CTIs had a 4% incidence of empyema; 37% of
elective and 66% of emergency CTIs had … The
estimated inter-rater reliability of 0.409 implies a 59% reduction in monthly
incidence, which, … based on the baseline sample incidence rate of 4.6%, implies
a decrease to an incidence rate of approximately
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-facguide.docx
January 01, 2017 - continuous subglottic suctioning showed that even when assuming the most pessimistic scenario of VAP incidence
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34.
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www.ahrq.gov/research/findings/final-reports/crctoolkit/crctoolkit4.html
April 01, 2018 - United States cancer statistics: 1999-2006 incidence and mortality Web-based report.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/tool4a_ed-setting.pptx
January 10, 2017 - CAP) is the 8th leading cause of death in the U.S.a
6 million cases of CAP reported annually a
High incidence
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www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet1.html
October 01, 2014 - Due to the rapidly growing number of Hispanics in many areas of the United States and their higher incidence