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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - their institutions include how to:
Engage patients and families in disclosure communication following adverse … 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.
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monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - patient safety practices in eight categories encompassing commonly occurring care and disease specific adverse … ADEs: Harms Due to Diabetic Agents
ADEs: Reducing Adverse Drug Events in Older Adults
ADEs: Harms … Systems
Summary of Evidence
Update
(Not reviewed)
The Clinical Pharmacist's Role in Preventing Adverse … Drug Events
Summary of Evidence
Update
(Not reviewed)
Protocols for High-Risk Drugs: Reducing Adverse … Evidence
Teach-Back
(Not reviewed)
(Not reviewed)
Summary of Evidence
ADEs: Reducing Adverse
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - drug event to warfarin (Adverse
drug events) … Adverse drug events. … Adverse Drug Events
• An adverse drug event (ADE) is an injury—including physical harm, mental harm, … Adverse Drug Events With Warfarin
Adult hospital patients with an anticoagulant-related adverse drug … Events
30-Day Mortality for Colorectal Surgery
Adverse Drug Events
Adverse Events With Hypoglycemic
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monahrq.ahrq.gov/news/newsletters/e-newsletter/818.html
June 01, 2022 - Study Finds Relationship Between Readmission Rates, Adverse Events in Hospitals . … Study Finds Relationship Between Readmission Rates, Adverse Events in Hospitals
Patients with pneumonia … admitted to hospitals with high readmission rates were more likely to experience adverse events, a new … The authors of the study, published in JAMA Network Open , cross-referenced Medicare patient-level adverse … records between 2010 and 2019, they found that patients were 13 percent more likely to suffer from an adverse
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
January 01, 2013 - know about patient safety and Limited English Proficiency (LEP) patients
Identify common causes of adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Nearly 25 million people in the United States (8.6%) are defined as LEP and therefore at risk for adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … TeamSTEPPS
01020304050Percent Type of Physical Harm
Types of Physical Harm Experienced From Adverse
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monahrq.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features
The QSRS:
Offers an expanded array of adverse event measures.
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monahrq.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
December 01, 2012 - (continued) Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients Slide 11: Systems … Identify common causes of adverse events for LEP and culturally diverse patients. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Return to Contents
Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients
Use … Language proficiency and adverse events in U.S. hospitals: a pilot study.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
April 01, 2016 - Identification and Analysis of Actual and Potential Adverse Events
a. … Do staff have access to a system for reporting adverse events?
c. … Is an attempt made to disclose within the first 24 hours following an adverse event?
h. … Do staff have access to a system for reporting
adverse events? … Is an attempt made to disclose within the first 24
hours following an adverse event?
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monahrq.ahrq.gov/news/newsletters/e-newsletter/868.html
June 01, 2023 - Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Video-Assisted Coaching Reduced Intubation-Associated Adverse Events in Children, but Apneic Oxygenation … Did Not
Adverse tracheal intubation-associated events—unwanted events that occur as a result of the … intervention in 14 pediatric intensive care units and found that apneic oxygenation did not reduce adverse … Researchers found that use of video laryngoscope coaching did reduce adverse tracheal intubation-associated
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monahrq.ahrq.gov/topics/a.html
April 22, 2024 - Information in Spanish
Topics Browse A - Z
A
Access to Care Adverse … Drug Events (ADE) Adverse Events Alcohol Use All-Payer Claims Ambulatory Care and Surgery
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monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-hernandez-boussard.html
April 01, 2024 - her career to analyzing “clinical big data” to identify quality and safety issues that can result in adverse … datasets on safety events, including AHRQ’s Healthcare Cost and Utilization Project (HCUP), she profiled adverse … Hernandez-Boussard also examined factors that could contribute to adverse events such as hospital surgical … Her research focuses on older patients and aims to mitigate the risk of adverse outcomes related to postoperative
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monahrq.ahrq.gov/patient-safety/resources/improve-discharge/index.html
July 01, 2022 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge
AHRQ PS Net Primer: Readmissions and Adverse … Toolkit To Improve Medication Reconciliation Across Care Settings
Six New Jersey Hospitals Reduce Adverse … Patient Safety and Team Communication Through Daily Huddles
AHRQ PSNet Primer: Medication Errors and Adverse
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
January 01, 2013 - The cost of adverse drug events in hospitalized patients.
JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care
Med 2007;35(11)2637-8.
Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … The costs and savings associated with prevention of
adverse events by critical care nurses. … allows users to track the change
in rate of any type of adverse event over time.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse … three-quarters of these 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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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
January 01, 2010 - for engaging patients and families in discharge planning
Nearly 20 percent of patients experience an adverse … three-quarters of these 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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monahrq.ahrq.gov/news/newsletters/e-newsletter/842.html
December 01, 2022 - Older Opioid Patients Experience More Adverse Events After Injury . … Older Opioid Patients Experience More Adverse Events After Injury
Chronic non-cancer pain Medicare … injury—such as a fall or traumatic brain injury—have a 1.4 times greater risk of future opioid-related adverse … According to an AHRQ-funded review in PLOS Medicine , the risk was highest in the 30 days before an adverse … emerge after opioid initiation may assist in the early detection of older patients at high risk for adverse
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
August 01, 2022 - Is there a clear process for communication among staff in response to adverse events? … Identification and Analysis of Actual and Potential Adverse Events:
Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events? … Is an attempt made to disclose within the first 24 hours following an adverse event?
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
August 01, 2022 - Is there a clear process for communication among staff in response to adverse events?
… Identification and Analysis of Actual and Potential Adverse Events
Is there a process in place for … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions?
… Do staff have access to a system for reporting adverse events?
… Is an attempt made to disclose within the first 24 hours following an adverse event?
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monahrq.ahrq.gov/research/findings/making-healthcare-safer/index.html
July 01, 2023 - Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse
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monahrq.ahrq.gov/research/findings/studies/index.html
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe … Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of … The study did not find significant differences in adverse events. AHRQ-funded; HS024511. … The objective of this observational cohort study was to compare rates of adverse functional outcomes