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healthcare411.ahrq.gov/news/newsroom/press-releases/smoking-cessation-disparities.html
December 01, 2023 - 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
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
April 01, 2016 - How to use this tool: Use the checklist to ensure that appropriate action is taken following an adverse … ■ Report any adverse event to the appropriate professional responsible for patient safety
events.
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healthcare411.ahrq.gov/antibiotic-use/acute-care/safety/index.html
June 01, 2021 - Use Commitment Poster (DOCX)
Antibiotic Time Out Tool (DOCX)
Identifying Antibiotic–Associated Adverse … Events Form (DOCX)
Learning From Antibiotic–Associated Adverse Events Form (DOCX)
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healthcare411.ahrq.gov/hai/pfp/index.html
July 01, 2020 - Condition Rate ( PDF , 237 KB)
To improve how the Nation tracks its progress on reducing HACs and other adverse … This patient safety surveillance system will capture information about HACs and other adverse events
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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - Contents
A Systems Approach
The sole objective of the event investigation and analysis of an adverse … event or near miss is the prevention of future adverse events. … When an adverse event occurs, too often, the focus is on an individual's performance and is corrected … other than the involved individual) that might have contributed to, facilitated, or even caused the adverse … The systems approach recognizes that all adverse events have multiple contributing factors, many of which
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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … responsible for item or Action Plan
Reporting Culture
Are policies in place to support reporting adverse … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place?
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healthcare411.ahrq.gov/es/programs/index.html?page=2
March 31, 2024 - To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse
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healthcare411.ahrq.gov/programs/index.html?page=2
April 28, 2024 - To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse
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healthcare411.ahrq.gov/data/qualityindicators/index.html
November 01, 2020 - hospital level, the QIs are used to support internal quality improvement, monitoring, and assessment of adverse … Patient Safety Indicators (PSIs) help hospitals assess the incidence of adverse events and in-hospital … More specifically, they focus on potential in-hospital complications and adverse events following surgeries
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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - care, where the complexity of the system and the fragility of the patients creates a greater risk for adverse … a 2-year AHRQ grant in 2005 to evaluate an emergency medicine clinical pharmacist program to avoid adverse … Fairbanks evaluated over 10,000 ED cases for adverse events, and interviewed ED physicians and nurses
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
February 21, 2023 - Cancer-Free
Survival
Outcomes Similar at 5 and 10 Years
Whole Breast
Irradiation (WBI) Acute
Adverse
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/870.html
June 01, 2023 - Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Associated With Financial Distress
An analysis of more than 132,000 individuals’ credit reports showed adverse … Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog
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healthcare411.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
January 01, 2004 - Because oral
anticoagulants are associated with preventable adverse events at
disproportionately high … high (INR > 4), or safe (INR
≤ 2 but ≥ 4), based on cutoff values associated with increased risks of adverse … 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.
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healthcare411.ahrq.gov/research/findings/studies/index.html?page=484
January 01, 2024 - 1279)
2015
(1430)
2014
(662)
2013
(195)
Topics
Access to Care
(417)
Adverse … Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention
Braithwaite S , Friedman … Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse … Keywords: Adverse Events, Hospitals, Medical Errors, Patient Safety, Quality Indicators (QIs)
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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.pptx
May 01, 2017 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … Fetal Monitoring
12
Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse … episode involving an abnormal fetal tracing
Disclosing any unintended outcomes using unit policy for adverse … Past adverse events related to EFM use
Synergy with related or similar initiatives
Interest and enthusiasm
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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.pdf
May 01, 2017 - 3
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 … • Past adverse events related to EFM use.
• Synergy with related or similar initiatives
(e.g., initiatives
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - Staff can use this decision tree when analyzing
an error or adverse event in an organization to help … 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.
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healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse … Simulations—that an L&D unit can use to teach team members how to apply CUSP to prevent obstetrical adverse
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/828.html
August 01, 2022 - Drug-drug interactions are responsible for up to 14 percent of adverse drug reactions in hospitalized … Articles featured this week include:
Quality measures for patients at risk of adverse outcomes in the … disproportionality analysis of drug-drug interactions of tizanidine and CYP1A2 inhibitors from the FDA Adverse
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/813.html
May 01, 2022 - Patient Safety found no evidence of the so-called “July Effect,” an increase in patient safety and adverse … 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