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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Care
Need for Change
Nine percent of all births in the United States involve serious obstetrical adverse … For more than a decade, poor teamwork and communication have remained the leading
causes of maternal adverse … Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Newborns
The goal of the AHRQ Safety Program for Perinatal Care is to decrease maternal and neonatal
adverse … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury)
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Care
Need for Change
Nine percent of all births in the United States involve serious obstetrical adverse … For more than a decade, poor teamwork and communication have remained the leading
causes of maternal adverse … Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Newborns
The goal of the AHRQ Safety Program for Perinatal Care is to decrease maternal and neonatal
adverse … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury)
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
April 01, 2011 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … Nearly 20 percent of patients experience an adverse event within a month of discharge, of which ¾ could … be prevented
Common complications post-discharge are adverse drug events, hospital-acquired infections … these events could have been prevented or ameliorated.1
Common post-discharge complications include adverse … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
February 24, 2008 - Introduction
Public and professional concern over patient safety, adverse health care events, and medical … Lucian Leape on the causes and prevention
of errors and adverse events in health care. … Preventing adverse drug events. Am J
Health Syst Pharm 1995; 52: 379-382.
6. Leape LL. … The nature of
adverse events in hospitalized patients. … Pharmacist
participation on physician rounds and adverse drug
events in the intensive care unit.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
January 01, 2014 - Ambulatory Medical Care Visits Due to Adverse Effects of Care
Importance: Adverse effects of medical … care can arise from medical and surgical procedures
as well as from adverse drug reactions. … Adult ambulatory medical care visits due to adverse effects of medical care
per 1,000 population, by … Adult ambulatory medical care visits due to adverse effects of medical care
per 1,000 population, by … Reducing the risk of adverse drug events in older adults.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
August 07, 2012 - Poor communication among staff is a root cause of many patient adverse and sentinel events.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Harney_89.pdf
May 01, 2007 - Adverse events identified during the pilot study included: hemangioma,
oropharyngeal bleed, bleeding … Additional
information was gathered (e.g., unit, service, education needed, adverse event), coded, and … On review of data obtained from the CHB Safety Events Reporting
System, adverse event rates in FY 2005 … There is no available literature describing the rate of readmissions for pediatric patients with an
adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/data/infographics/patient-safety-issues.pdf
May 21, 2020 - diagnostic errors
were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
April 12, 2018 - .
■ Answer your questions.
1 in 9
emergency
department admissions
are related to an
adverse drug
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ce.effectivehealthcare.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 … Management in this facility seems interested in patient safety only after an adverse event happens
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
March 01, 2017 - SLIDE 27
SAY:
Communication following an adverse event can been especially challenging. … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … important to remember that residents and family members can experience a number of emotions when an adverse … event occurs, so communication about an adverse event should be compassionate and sensitive.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher2.pdf
January 01, 2016 - Complications of care and adverse events occurring in the inpatient
hospital setting that may be related … possibility of underestimating the prevalence of some of the
PSIs attributable to inpatient care: adverse … These data help
estimate the volume of those adverse events that occur in the admission during
which … The Selected Infections Due to Medical Care hospital-level PSI was
developed to capture adverse events … The use of ICD-9-CM diagnosis
and procedure codes from administrative data to identify potential adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
March 01, 2016 - Staff can use this decision tree when analyzing an error or
adverse event in an organization to help … a multidisciplinary team approach, known as Root
Cause Analysis (RCA) to study health care-related adverse … Sorry
http://www.nhsla.com/Claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf
Although victims of adverse … presents the principles of a just culture, a nonpunitive
environment that encourages reporting of adverse … /psnet.ahrq.gov/primers/primer/23
A growing evidence base supports specific strategies to prevent adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
November 18, 2019 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or
adverse events … Management in this facility seems interested in patient safety only
after an adverse event happens
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
July 12, 2018 - diagnostic errors
were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/teamattitude.pdf
March 21, 2014 - Adverse events may be reduced by maintaining an
information exchange with patients and their families
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-040913.ppt
October 01, 2015 - Infrastructure advisory
Engaging in everyday care
How-to strategies
Engaging with after an adverse … on the CUSP team
Provide input to improve policies and procedures
Advise on how to communicate an adverse
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4t_combo_pdi08-postophemorrhage-bestpractices.pdf
May 16, 2016 - http://www.who.int/surgery/publications/Postoperativecare.pdf
• Anticoagulant Toolkit: Reducing Adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanage_quickstartfull.pdf
December 15, 2016 - to medication reconciliation and medication management are well
documented.2-5 One study found that adverse … It will also help you identify patient behaviors that
may be putting them at risk for an adverse drug … Adverse drug events in U.S. adult ambulatory medical
care.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-dec2013.pptx
January 01, 2013 - in pt. harm (Abstoss et al., 2011)
Rates of RRS activations that resulted in codes (Donahue, 2011)
Adverse … Use of evidence-based practice
Handoffs
Efficiency
Reduced care delays
Decision time
Safety outcomes
Adverse