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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/how-to-use.html
July 01, 2023 - team members how to apply the Comprehensive Unit-based Safety Program (CUSP) to prevent obstetrical adverse
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pbrn.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Reducing Adverse Events Related to Anticoagulants .
Implicit Bias Training .
Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .
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pbrn.ahrq.gov/news/newsletters/e-newsletter/892.html
December 01, 2023 - Making Healthcare Safer IV will provide evidence on 11 additional safety topics, including reducing adverse … Articles featured this week include:
Prescription opioid dose reductions and potential adverse events
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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-slides.html
July 01, 2023 - Slide 14: Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse events … Have a process in place to review serious maternal or neonatal adverse outcomes. … Consider these factors:
Unit data suggesting adverse events or near misses that may have been minimized
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pbrn.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis . … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality
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pbrn.ahrq.gov/pbrn-registry/oregon-rural-practice-based-research-network
May 06, 2013 - diesease related interests: Access to care-dental services, drug sampling policies, medication errors and adverse
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pbrn.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
July 01, 2018 - How to communicate an adverse event to patients and family members.
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pbrn.ahrq.gov/patient-safety/reports/national-action-plans.html
February 01, 2018 - National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies
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pbrn.ahrq.gov/news/newsletters/e-newsletter/872.html
July 01, 2023 - process can enrich clinicians’ understanding of patient and family experience and reduce harms following adverse … emergency departments to provide nonemergency care to residents, potentially placing residents at risk of adverse
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pbrn.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
January 01, 2024 - improve patient and family
engagement and self-efficacy, improving care coordination and reducing adverse … Adverse drug events and medication errors in Australia. … Incidence and Preventability of Adverse Drug Events Among Older
Persons in the Ambulatory Setting. … Incidence and preventability of adverse drug events among older
persons in the ambulatory setting. … Adverse reactions as a cause of hospital admission in the aged. Drugs Aging. 1992;2(4):356-367.
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pbrn.ahrq.gov/hai/hai-carb-funding.html
November 01, 2021 - determine the clinical efficacy and effectiveness of preventive interventions including unintended adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - to establish an initiative to help States and health care systems test
new models of care delivery, adverse … Clinician responses were more varied and were affected by
type of adverse event, but they did agree … Clinician responses were more varied and were
affected by type of adverse event, but clinicians did … These adverse events are relevant because obstetric and perinatal-related claims
are among the most … An ACEx2 program differs from other disclosure and offer models
“because it focuses on adverse events
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pbrn.ahrq.gov/news/newsletters/e-newsletter/856.html
March 01, 2023 - Articles featured this week include:
Automated capture of intraoperative adverse events using artificial … Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated
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pbrn.ahrq.gov/news/newsletters/e-newsletter/878.html
August 01, 2023 - (Source: JAMA Network Open , Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem … include:
Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse
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pbrn.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality … Risk factors for opioid-related adverse drug events among older adults after hospitalization for major
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pbrn.ahrq.gov/practiceimprovement/index.html
August 01, 2022 - Prevention
Tools to assist nursing homes that have electronic medical record systems to prevent adverse
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pbrn.ahrq.gov/sdoh/about.html
February 01, 2020 - Trauma (e.g., adverse childhood experiences, domestic violence, elder abuse).
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-may2015.pptx
January 01, 2015 - Safety in the US: Ongoing Problems
Institute of Medicine, 1999
44,000-98,000 deaths per year due to adverse … events
Office of the Inspector General, 2010
180,000 deaths per year due to adverse events
North Carolina … 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
I-PASS
Slide ‹#›
Results: Medical Error and Preventable Adverse … JAMA 2013; 310: 2262-2270
Pre-RHB Post-RHB p-value
Medical Errors 33.8 18.3 <0.001
Preventable Adverse … implementation associated with:
Primary outcome
A significant reduction in overall error rates and preventable adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
May 01, 2017 - This principle calls for L&D unit teams to evaluate their processes and learn from adverse events, errors … to the Rapid Response toolcall
In addition, clinical teams can debrief and analyze near misses and adverse … debriefings, a regular forum with a multidisciplinary team for reviewing serious maternal or neonatal adverse … Consider these factors:
· Unit data suggesting adverse events or near misses that may have been minimized
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
October 01, 2017 - Perinatal Safety
13
Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse … Response Call Log can facilitate a debrief
Have a process in place to review serious maternal or neonatal adverse … Consider these factors:
Unit data suggesting adverse events or near misses that may have been minimized