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Showing results for "adverse events".
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101. Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
     July 01, 2023 - unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … Finally, unit staff should disclose any unintended outcomes related to EFM use using unit policy for adverse … events. … Past adverse events related to EFM use.

102. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
     May 01, 2017 - Professional Liability EFM interpretation and management are a common issue in litigation involving adverse … events, and the contribution of EFM use, EFM interpretation, and communication of EFM findings. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events 17 AHRQ Safety Program for Perinatal Care Electronic Fetal Monitoring 17 Unit Next Steps … Past adverse events related to EFM use Synergy with related or similar initiatives Interest and enthusiasm

103. TeamSTEPPS®: Research/Evidence Base | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/teamstepps/evidence-base/labor-delivery.html
     July 01, 2015 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events … Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized … Impact of a comprehensive patient safety strategy on obstetric adverse events.

104. Major Hospital Quality Measurement Sets | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/talkingquality/measures/setting/hospitals/measurement-sets.html
     February 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … The Patient Safety Indicators (PSIs) identify adverse events occurring during hospitalization. … They provide information on potential in-hospital complications and adverse events following surgeries

105. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
     May 01, 2023 - events and close calls. … These organizations consistently minimize adverse events despite carrying out intrinsically complex … Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primers/primer … /23 A growing evidence base supports specific strategies to prevent adverse drug events (ADEs). … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

106. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     monahrq.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - Forty-five percent of the errors had adverse consequences. … events. … Confronting an adverse medical event collaboratively helped both patients and providers with patients … Patient perspectives of patient--provider communication after adverse events. … Adverse events in primary care identified from a risk- management database.

107. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
     January 01, 2019 - events … • Implement a Care for the Caregiver program for providers involved in adverse events. … • Investigate and analyze an adverse event to learn from it and prevent future adverse events. … These organizations consistently minimize adverse events despite carrying out intrinsically complex … drug events (ADEs).

108. New Challenge Competition Launched To Update and Re-Create TeamSTEPPS Videos | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/news/newsletters/e-newsletter/813.html
     May 01, 2022 - section News Newsroom Blog Newsletter AHRQ News Now Events … Patient Safety found no evidence of the so-called “July Effect,” an increase in patient safety and adverse … events after the annual summertime resident changeover. … patient records abstracted and analyzed using the Medicare Patient Safety Monitoring System, changes in adverse … Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions

109. Rapidresponse Facguide (doc file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
     May 01, 2017 - This principle calls for L&D unit teams to evaluate their processes and learn from adverse events, errors … to the Rapid Response toolcall In addition, clinical teams can debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated. … Consider these factors: · Unit data suggesting adverse events or near misses that may have been minimized … Regularly debrief after rapid response events, and solicit ongoing feedback from staff and patients.

110. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/labor-delivery/index.html
     July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures.

111. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
     monahrq.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
     January 01, 2004 - Because oral anticoagulants are associated with preventable adverse events at disproportionately high … events,4, 37 such as thrombotic events (under-treatment) or bleeding (over- treatment). … events are common18 and warfarin is involved in preventable adverse drug events at rates disproportionate … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse drug events in ambulatory care. NEJM 2003 348(16):1556– 64. 19.

112. Survey on Patient Safety (facility version) (doc file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     November 15, 2019 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … to ask questions when something does not seem right (1 (2 (3 (4 (5 SECTION D: Frequency of Events … Management in this facility seems interested in patient safety only after an adverse event happens … Shift changes are problematic for patients in this facility (1 (2 (3 (4 (5 SECTION G: Number of Events

113. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
     October 01, 2017 - Perinatal Safety 13 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated Debrief among clinical team after rapid … Response Call Log can facilitate a debrief Have a process in place to review serious maternal or neonatal adverse … Consider these factors: Unit data suggesting adverse events or near misses that may have been minimized … Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to

114. Executive Briefing
     monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/leadership-brief/ts-leadershipbrief.pptx
     January 01, 2013 - 10 years and identified communication failure as the leading root cause of sentinel events. … Outcome Score, which describes the adverse event score per delivery A 50% decrease in the Severity Index … , which measures the average severity of each delivery with an adverse event Intensive Care Units2 After … years and identified communication failure as the leading root cause of sentinel events. … events and close calls. 19 What Does it Cost?

115. First-of-its-Kind Study Examines Disparities in Healthcare Costs and Outcomes of Cigarette Smoking in the United States | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/news/newsroom/press-releases/smoking-cessation-disparities.html
     December 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … AHRQ Social Media AHRQ Stats Impact Case Studies Blog Newsletter Events … policymakers conduct cost-benefit analyses that accurately reflect the burden of healthcare costs and adverse … “Disparities in medical spending, as well as adverse health outcomes, are continuing to increase over

116. Search Evidence-Based Reports | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/research/findings/evidence-based-reports/search.html?page=1
     November 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Permanente Research Affiliates Report Status: Final Efficacy of Dental Services for Reducing Adverse … Events in Those Receiving Chemotherapy for Cancer Date: July 2023 Report Type: Rapid Evidence Product … Scientific Resource Center Report Status: Final Efficacy of Dental Services for Reducing Adverse … Events in Those Undergoing Insertion of Implantable Cardiovascular Devices Date: July 2023 Report

117. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
     April 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Cards and Outcome Measurements Report Protocol Opioid Stewardship Report Protocol Reducing Adverse … Events Related to Anticoagulants Report Protocol Implicit Bias Training Report Protocol … Deprescribing Report Protocol Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … Drug Events Report Protocol Failure To Rescue—Rapid Response Systems Report Protocol Prevention

118. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/news/newsroom/case-studies/201509.html
     January 01, 2018 - AHRQ Social Media AHRQ Stats Impact Case Studies Blog Newsletter Events … the technicians' work, the E.D. pharmacist can interpret the patient's medication history to look for adverse … events, one of the many reasons patients come to the E.D. … Study Identifier: 2015-09 AHRQ Product(s): Research Topic(s): Adverse … Drug Events (ADE), Outcomes, Patient Safety, Provider: Pharmacist Geographic

119. AHRQ Views: Biden Administration Tackles Financial Strains on Healthcare Consumers | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/news/newsletters/e-newsletter/892.html
     December 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Making Healthcare Safer IV will provide evidence on 11 additional safety topics, including reducing adverse … events related to anticoagulants, opioid stewardship and addressing fatigue and sleepiness of clinicians … Articles featured this week include: Prescription opioid dose reductions and potential adverse events

120. AHRQ-Funded Patient Safety Research Featured in Health Affairs | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/reports/healthaffairs.html
     March 01, 2019 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … patient-safety efforts nationwide, AHRQ has funded studies that aim to reduce medication errors and adverse … events, improve communication strategies that support better care coordination, and lower the rate of