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healthcare411.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
November 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention provides a strategy for preventing adverse … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … Adverse Events
Pressure Ulcer Prevention .
Pressure Ulcer Healing .
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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
August 01, 2022 - An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … Do:
Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - primary care teams should consider individual patients’ risk factors for developing postdischarge
adverse … If left
unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … facilitating the implementation of these elements is important to enhance patient
safety since the risk of adverse … new approach primary care teams can use to engage
patients and families to help reduce postdischarge adverse
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
August 07, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form.
II.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/prp/prp-wound-care.pdf
September 17, 2020 - • There is no statistically significant difference in adverse events and serious adverse
events between … There was no
statistically significant difference in death, total adverse events or serious adverse … Adverse Events
Appendix L. … There was no statistically
significant difference in adverse events (AEs) and serious adverse events … Categories of adverse events
Type of Adverse Events Example
Dermatological Adverse event Dermatitis
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - regarding the definition of true postoperative respiratory failure,
it still remains an important patient adverse … at increased risk for postoperative respiratory failure
to better prepare clinicians to anticipate adverse … Decreased central nervous system input (head injury, ingestion of central nervous system
depressant, adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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healthcare411.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology ( PDF , 109 KB ) … Voluntary Adverse Event Reporting in Rural Hospitals ( PDF , 478 KB ) Charles P. … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … News Media and Health Care Providers at the Crossroads of Medical Adverse Events ( PDF , 129 KB ) … Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … More than three-fourths
of PSOs offered analytical support for adverse events,
and a similar share … Analytic Support for Adverse Events. … Copyright 2015 ECRI Institute. www.ecri.org
• Adverse events
• Near misses
• Hazards
• Common Formats … Notably, they require all members wishing
to submit information on an adverse event to their PSO
to
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healthcare411.ahrq.gov/news/newsroom/case-studies/cquips0609.html
October 01, 2014 - Importantly, the survey also highlighted that staff were more uncomfortable with filing reports of adverse … team targeted its initiatives to address three specific dimensions of patient safety: reporting of adverse … events, handoffs and communication, and feedback and awareness of adverse events.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - risk” will go on to develop MCC
• Targeted interventions to improve health and reduce the
risk of adverse … interventions for those who have complex
management issues and who are at “high risk” for
avoidable adverse
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/852.html
February 01, 2023 - Researchers analyzed electronic health record data for 900,635 patients to identify the costs of fall-related adverse … treat gout as well as other conditions, but it has potentially serious drug interactions that can cause adverse … Food and Drug Administration’s Adverse Event Reporting System from January 2004 through June 2020. … It found a total of 787 reports that pointed to an adverse event from a colchicine drug interaction.
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healthcare411.ahrq.gov/sops/about/patient-safety-culture.html
March 01, 2022 - 2
Hospitals with more positive SOPS scores had:
Lower rates of in-hospital complications or adverse … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/index.html?page=2
April 05, 2022 - ascending
Top Story
April 5, 2022
Dental Opioid Prescriptions Associated With Adverse … Patient-Generated Health Data Into Electronic Health Records
February 8, 2022
Opioid Prescribing, Adverse … Change, Environmental Justice and AHRQ
October 5, 2021
Drug Label Changes Could Reduce Adverse
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
October 01, 2017 - of life
(QoL), activities of daily living (ADL), dyspnea, sleep quality, exercise tolerance, and adverse … emergency room visits,
disease exacerbations, QoL,
ADL, dyspnea, sleep quality,
exercise tolerance, and adverse … (KQ 5)
Adverse
Events
using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … life (QoL)
• Activities of daily living (ADL)
• Dyspnea
• Sleep quality
• Exercise tolerance
• Adverse
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
March 11, 2022 - Indian Health
Service
• Enhanced Adverse Event Reporting Capabilities:
o Reporting of adverse events
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/831.html
September 01, 2022 - Potentially inappropriate medication administration is associated with adverse postoperative outcomes … Risk of metabolic and cardiovascular adverse events with abiraterone or enzalutamide among men with advanced … Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia … Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare
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healthcare411.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Older adults have a high prevalence of chronic pain and are especially vulnerable to adverse events from … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - Slide 4
SAY:
Further, EFM interpretation and management is a common issue in litigation involving adverse … 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 … findings.
· Whether timely and appropriate clinical responses occur with respect to EFM findings.
· Past adverse
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healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
July 01, 2023 - Background
Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse … inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk of adverse
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healthcare411.ahrq.gov/research/findings/evidence-based-reports/search.html
May 01, 2024 - Affiliation: RTI International—University of North Carolina at Chapel Hill Report Status: Final
Adverse … Status: Final
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … International—University of North Carolina at Chapel Hill Report Status: Final
Reducing Adverse