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21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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

31. 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

32. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
    January 01, 2024 - No operator injuries occurred with a redesigned instrument tray. … Complications of CTI in one study of 426 consecutive patients occurred in 21%. … Undrained pneumothorax, hemothorax, or effusion despite CTI occurred in 35 patients. … In one of these patients, the air re-accumulation occurred after hospital discharge. … In one patient, this occurred 5 days after hospital discharge (Fig. 5).

33. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
    November 01, 2017 - It displays the number of falls that occurred and the risk factors associated with the falls. … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … For each of the months (1 or 3) included in the report, any fall that occurred before the report date … , Shift during which the fall occurred, Time at which the fall occurred, The location of the fall

34. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
    April 02, 2008 - to execute a specific task, whereas “team reformation” occurred when team membership changed in a … Each behavioral marker was scored using the following scale: • “0” Behavior occurred at or below … • “2” Behavior occurred more than 90 percent of the times when prompted by the event set. … emergency measures; and planning for an emergency intervention occurred. … Leadership transfer occurred continuously throughout an obstetrics emergency.

35. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - , but the medication did not reach the patient C An error occurred that reached the patient but did … but no patient harm Error, harm E An error occurred that resulted in the need for treatment or … hospitalization and caused temporary patient harm G An error occurred that resulted in permanent … patient harm H An error occurred that resulted in a near-death event (e.g., anaphylaxis, cardiac … A 5-month time frame was identified; in an effort to minimize bias, one that occurred immediately prior

36. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
    January 01, 2003 - The total number of links was summarized and grouped, then the number of activities that occurred for … Calculations were made to show the cognitive load at the time each interruption occurred and at the … Omissions for RN #3 occurred with a cognitive stacking load of 16, 18, 17, and 16 respectively. … Omissions occurred at various times with respect to a nurse’s cognitive stacking measure. … For example, an omission occurred with a nurse’s cognitive stacking as low as 5 and as high as 20.

37. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits - Functional Specifications (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
    February 01, 2018 - type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily. … type occurred daily.

38. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
    August 01, 2022 - The patient and/or family have a reasonable expectation to be informed when a harm event has occurred … of this initial conversation is to advise the patient and/or family that an adverse event may have occurred … During disclosure, patients and families generally want a clear, explicit statement that an event has occurred … what happened in a way that is easy to understand, explain what is known about why the adverse event occurred … If the event was preventable and occurred due to error, the communicator should: Consider using

39. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - information, other than event reports, that might provide information indicating that a CANDOR event has occurred … create a cohesive environment for informing the organization as to whether a CANDOR event may have occurred … implement the best practice of creating a hotline for staff to call when they feel a CANDOR event has occurred … Risk Management can also provide ongoing support to managers on the unit(s) where the event occurred. … Also, the location where the event occurred is generally no longer intact, so information that could

40. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
    May 19, 2003 - Brennan et al.1 reported that adverse events occurred in 3.7 percent of the selected cases (95% confidence … Thomas et al.2 reported that in this sample, adverse events occurred at a rate of 2.9 percent (with … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … in 2003.4 Not surprisingly, the results of the studies of adverse events that occurred in Utah and … This education occurred on the patient care units 24 hours a day for the 5-day process.