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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
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/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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.ahrq.gov/research/findings/evidence-based-reports/search.html
April 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
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monahrq.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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monahrq.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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monahrq.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)