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Showing results for "adverse".

101. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Near-miss reporting systems have many potential benefits over adverse event detection systems. … “Near-miss” Reporting: Implications for Human Protection 189 Adverse event example. … to and management of the adverse event would have likely been less timely. … Systems analysis of adverse drug events. ADE Prevention Study Group. … Reporting of adverse events. N Engl J Med 2002;347(20):1633–8. 39.

102. Candor-Impguide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
     April 01, 2016 - should expect to implement a number of leading practices to improve communication and response to adverse … Recent research shows a significant correlation between the frequency of adverse events and malpractice … It also emphasizes the organization’s commitment to improve the reporting and monitoring of adverse … event (see Adverse Event [Reasonable Care] and Adverse Event [Unreasonable Care]). … event • Number of adverse events reported >24 hours after occurrence – Severity level of adverse

103. Puh-Factraining-Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
     December 15, 2016 -  Nursing home staff generally do a good job of investigating and following up after an adverse event … It is more difficult for staff to identify which residents are at risk for a future adverse event … The reports:  Focus on preventing adverse events.  Are proactive rather than reactive. …  Improve root cause analyses when adverse events occur. … Discussion questions are tailored to the On-Time adverse event being addressed.

104. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2011-12.html
     January 01, 2018 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for special … Normalized to 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharges Adverse … 17,000 0.51 Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events

105. Staff-Safety-Assessment (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/staff-safety-assessment.docx
     June 01, 2021 - Safety Assessment PURPOSE OF THIS FORM: To discuss issues that may result in antibiotic-associated adverse … events or have the potential to cause adverse events that could negatively impact patient safety.

106. Data Measures Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
     January 01, 2017 - event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur. … event occur Target Low adverse event rate Mobility NOT Intubated: Distribution of Adverse Events … event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur.

107. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
     June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated

108. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated … vs. 2010, and Baseline Projections Made in 2011 on the Additional Inpatient Mortality per HAC Adverse … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that have implemented

109. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … Human,” as reported from the 2010 Medicare data: 13.5% of hospitalized beneficiaries experienced an adverse … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … As we saw in the “Do No Harm” Video, families reported how the silence they experienced after the adverse … Patients are looking for the actions the organization is doing to prevent and learn from the adverse

110. Prologue: Laying the Foundation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
     July 10, 2008 - Challenges of reporting quickly give rise to challenges of encoding and organizing the adverse event … Strategies and efforts aimed at adverse event surveillance, creating useable taxonomies, and addressing … Another paper examines the perceptions of health care leaders and news media professionals related to adverse … Risk is treated by safety scientists as the likelihood that exposure to a hazard will lead to adverse … underlying hazards and assessing risk—that is, the probability that exposure to a hazard will lead to an adverse

111. What Exactly Is Patient Safety? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse … The realization that adverse events often occur because of system breakdowns, not simply because of … Transparency and Learning The idea that adverse events could yield information was not new, but as it … The goal of the field of patient safety is to minimize adverse events and eliminate preventable harm … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 15.

112. Improving Antibiotic Use is a Patient Safety Issue
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
     November 01, 2019 - Issue AHRQ Safety Program for Improving Antibiotic Use – Acute Care 5 5 Antibiotic-Associated Adverse … events3 ~25% of these patients developed antibiotic-associated adverse events after hospital discharge … Most adverse events had some clinical ramifications Additional hospitalizations (3%) Prolonged hospital … Approximately 20% of hospitalized patients develop antibiotic-associated adverse events. … Association of Adverse Events with Antibiotic Use in Hospitalized Patients.

113. Prioritization Worksheet (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 05, 2016 - • Appropriate comparator: When trying to identify the cost attributable to an adverse event captured … Patients who experience adverse events often tend to have more comorbidities and other risk factors … and thus have accrued more costs even prior to the adverse event. … Therefore, choose a group that did not experience the adverse event that is as comparable as possible … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost

114. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Human Services’ Office of the Inspector General, states that “patients may be experiencing unnecessary adverse … Of the preventable adverse drug events in nursing homes, 70 percent occurred at the monitoring stage … The Flow Records contain specific MDS items that may indicate adverse medication effects associated … Epidemiology of adverse drug events in the nursing home setting. Drugs Aging 1995;7:203–11. 17. … Incidence and preventability of adverse drug events in nursing homes.

115. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     November 06, 2017 - It uses the electronic medical record, or EMR, to make staff aware of residents at risk of adverse … The reports:  Focus on preventing adverse events.  Are proactive rather than reactive. … These questions explore what the facility does to screen for risk of an adverse event. …  Improve root cause analyses when adverse events occur. … Discussion questions are tailored to the On-Time adverse event of interest.

116. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
     August 01, 2022 - Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Contributing factor: additional elements that contributed to the adverse event, many of which are outside … Event review: the overall process of assessing an adverse safety event to determine contributing factors … Latent hazard: the hidden problems within health care systems that contribute to adverse events

117. Translating Patient Safety Research into Clinical Practice (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Were there adverse effects? What was the impact on quality of life? … Relationship between medication errors and adverse drug events. … Incidence of adverse events and negligence in hospitalized patients. … Computer adverse drug event (ADE) detection and alerts. … The clinical pharmacist’s role in preventing adverse drug events.

118. Prologue: Technology and Medication Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
     July 25, 2008 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … approaches have been proposed and tried over the years to improve medication management and minimize adverse … patient-controlled analgesia (PCA), and monitor the medication use of Medicare beneficiaries at high risk of adverse

119. Engage Patients and Families for Perinatal Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
     May 01, 2017 - • Discuss how to communicate an adverse event to patients and family members. … Immediately after an adverse event, care providers: • Provide care. … SAY: Patients and family members experience a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent. … • Organizations need to engage in strategies to address adverse events.

120. Cusp Patient Family Engagement Facilitator Notes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     September 13, 2013 - improve communication among patients, families, and clinicians; and · Discuss how to communicate an adverse … Medical providers are committed to caring for their patients; however, adverse events can happen. … Immediately after an adverse event, care providers: · Provide care. … Slide 25 SAY: Adverse events are often system failures. … Rarely does an adverse event occur as a result of intent.