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61. 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

62. 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

63. 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

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40819/psn-pdf
    January 07, 2015 - Although fewer overall errors occurred with the new system, the reduction in administration errors occurred

65. 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

66. 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.

67. 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

68. 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

69. 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

70. 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

71. 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

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36342/psn-pdf
    March 02, 2011 - Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed … As with prior studies  using chart review, reviewer's agreement on whether an error occurred was only

73. 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

74. 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

75. Statistical Brief #147
    hcup-us.ahrq.gov/reports/statbriefs/sb147.jsp
    January 01, 2013 - ED visits for influenza occurred at a rate of 161.8 per 100,000 population in 2008 compared to 417.5 … ED visits for influenza occurred at a rate of 417.5 per 100,000 population in 2009 compared to 161.8 … In 2008, peak activity occurred in February (79.9 ED visits per 100,000 population). … In 2009, peak activity occurred in October (125.2 ED visits per 100,000 population). … *The rates are based on hospitalizations that occurred September through March (influenza season).

76. 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.

77. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. | PSNet
    psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
    February 16, 2011 - Prior research revealed that patients wanted the physicians to apologize for the error, explain how it occurred … Approximately half of respondents declined to explain how the error occurred or discuss specific plans

78. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
    psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
    May 27, 2011 - Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription … /documentation and administration, while outpatient errors occurred most frequently during prescribing

79. Telehealth and Emergency Medicine: A Consensus Conference to Map the Intersection of Emergency Medicine and Telehealth - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r13hs027528-clark-final-report-2021.pdf
    January 01, 2021 - Co-chairs reviewed the summaries and ensured no overlap occurred. … The sixth step occurred on Day 1 of the virtual conference. … The seventh step occurred on Day 2 of the conference. … The eighth step occurred after the conference. … Round 2 of the voting occurred after the first conference day, and round 3 occurred live in the second

80. From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. | PSNet
    psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
    July 22, 2020 - The investigators found that errors occurred at each stage of the process, with a small but significant … These errors often occurred when providers entered free-text instructions into the e-prescribing system