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Slide Presentation from the AHRQ 2007 Annual Conference

Median Event Rates over 9 Quarters
Critical Access and non Critical Access Hospitals
WV Patient Safety Project 2005-7

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Event Category	Median Rate/1,000 Bed Days
Event Category	Critical Access Hospitals (CAH)	non-Critical Access Hospitals (Non CAH)
Unobserved falls	5	3.4
Observed falls	0.9	0.6
Elopement	1.9	1.0
Delay in test/treatment	1.3	0.5
Lab specimen-related	1.7	1.0
Staff injury/exposure	5.1	2.5
Omitted Med Dose	2.1	1.0
Wrong Drug	1.6	0.9
Wrong Dose	1.5	0.8
Adverse Drug Reaction	0.4	1.1
Patient Misidentification	0.6	0.5

CAHS report more events than other facilities. May reflect .....
Greater attention to reporting?
Smaller, more intimate.