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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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
-
patientregistry.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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patientregistry.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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patientregistry.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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patientregistry.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