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21. Conducting a Morning Briefing | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
    December 01, 2012 - This tool provides a structured approach to help physicians and nurses identify the problems that occurred … If an adverse event occurred, you should also use the Learn From Defects Form.

22. Hospital Evacuation Decision Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevac4.html
    July 01, 2018 - Post-Event Evacuation Decision Guide Post-event evacuations have occurred either following Advanced … Sequence in a Post-Event Evacuation If the decision is made to begin an evacuation after the event has occurred … filled with water from the nearby Haw Creek and power was lost. 53 The full evacuation of 157 patients occurred

23. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - events were categorized into two taxonomies: (1) the segment of emergency care in which the event occurred … Patient visits were eligible for inclusion if (1) the visit occurred in the adult emergency department … An additional category, transitions, was added to account for periods when an event occurred during … The nonideal care events were categorized into the segment of care in which they occurred (Figure 1) … Significant time was spent distinguishing the true process from workarounds, which occurred between

24. Objective Outcomes Data Collection Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/vae/objective-outcome-tool.html
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

25. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - There is no evidence in these reports that any other type of patient safety concern occurred. … In several instances, the exposure occurred because staff were not following PPE protocols, such as … In other cases, the exposure occurred with an asymptomatic individual, and was later identified when … Additional near misses occurred when the wrong blood product (e.g., fresh frozen plasma versus COVID … PSOs generally provided data elements for the location in the facility where the event occurred and

26. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
    March 12, 2008 - The authors explained that these problems occurred when the pharmacy was closed and when all medications … Of the 59 instances of override, 17 (28.8 percent) occurred during a first shift (7:00 am to 3:30 pm … ); 31 (52.5 percent) occurred during a second shift (3:00 pm to 11:30 pm); and 11 (18.6 percent) occurred … Forty-five overrides (76.3 percent) occurred on weekdays. … The largest number of overrides occurred during the second shift, which was also when the majority of

27. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/objective-outcome-tool.docx
    January 01, 2017 - Total number of episodes of mechanical ventilation How many episodes of mechanical ventilation have occurred … Total number of deaths How many deaths have occurred in the patients who have been or were mechanically

28. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
    August 01, 2022 - Confirmation and Consensus Meeting Announcement Template As you may know, a patient care incident occurred

29. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
    January 01, 2024 - The intervention schedule had no extended work shifts, and 96 percent of work hours occurred within … the 16 hours scheduled, in contrast to the traditional schedule, in which 58 percent of work hours occurred … Intercepted serious intern errors occurred 27.9% more frequently on the traditional schedule than on … No adverse events occurred. … A total of 61 observed sessions occurred over the 12-month period, during which 183 simulations occurred

30. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue), but it has occurred

31. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - period the IOM report was released), we examine potentially preventable adverse medical events that occurred … The unit of observation was any major surgery admission (identified as the “index” surgery) that occurred … The surgeries occurred at 1,725 hospitals nationwide. … potentially preventable adverse medical events only cases in which the evidence that such an event occurred … Thus, there may have been many more preventable safety events (as well as close calls) that occurred

32. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reports.html
    November 01, 2017 - within the facility’s electronic medical record, such as nurse assessments, and represent changes that occurred … the facility’s electronic medical record as determined by the facility and may represent changes that occurred … Fall Risk Factors Report provides information regarding the number and percentage of falls that have occurred … For each month, it displays the number of falls that occurred and the risk factors   associated with … Shift during which the fall occurred. Time at which the fall occurred.

33. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
    November 19, 2015 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … the reduction in the rate of HACs, we estimate that approximately 790,000 fewer incidents of harm occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

34. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
    December 01, 2016 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … the reduction in the rate of HACs, we estimate that approximately 798,000 fewer incidents of harm occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

35. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
    November 19, 2015 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … the reduction in the rate of HACs, we estimate that approximately 790,000 fewer incidents of harm occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

36. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
    December 01, 2016 - patients over the 4 years (2011, 2012, 2013, and 2014) relative to the number of HACs that would have occurred … precise causes of the decline in patient harm are not fully understood, the increase in safety has occurred … the reduction in the rate of HACs, we estimate that approximately 798,000 fewer incidents of harm occurred … in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level (Exhibit … Cumulatively, approximately 2.1 million fewer incidents of harm occurred in 2011, 2012, 2013, and 2014

37. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - This format helps to utilize the information found in the investigation to understand why the event occurred

38. Appendix G. Safety and Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apg.html
    September 01, 2013 - difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue), but it has occurred

39. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - Categories E through H errors not only occurred and reached the patient but also caused harm. … In one study of nationally representative US data, extra vaccination occurred in 21% of young children … Harmful errors occurred with all cardiovascular drug classes. … However, because over half the errors occurred at the administering stage of medication processing, … Not surprisingly, a large majority of reported pediatric antidepressant medication errors occurred

40. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
    January 01, 2024 - The pump observations occurred 1 month before Smart IV pump implementation and 5 months 4 after … Forty-six hours of meeting time occurred over 4.5 months, representing 600 person-hours of time. … The second round of usability testing occurred with what was ultimately the final pump. … There were nine different units and the emergency department on which the observations occurred. … Staff were unaware and surprised that an UNDER- infusion most likely occurred in these cases.