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pbrn.ahrq.gov/news/newsletters/e-newsletter/874.html
August 01, 2023 - available to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse … Articles featured this week include:
Anticoagulation-associated adverse drug events in hospitalized
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pbrn.ahrq.gov/pbrn-registry/dartmouth-practice-based-research-network
January 01, 2012 - health or disease related issues: Use of Benzodiazephines/Benzodiazepine Agonists in Chronic Insomnia, Adverse
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pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual support … Staff members are concerned that we could have an adverse event due to breakdowns in team skills.
… prophylactic use of beta-blockers to prevent intra-operative myocardial ischemia]; decreased rates of adverse
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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
July 01, 2023 - 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/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
October 01, 2015 - • AHRQ QIs are indicators of hospital quality and
adverse events that patients may experience as … • Pediatric Quality Indicators (PDIs) reflect quality of care
inside hospitals and adverse events … • The PSIs are a set of 18 hospital-level indicators of
safety-related adverse events following operations … and Safety
• The PDIs are a set of 16 indicators that reflect quality
of care inside hospitals and adverse
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pbrn.ahrq.gov/evidencenow/projects/alcohol/index.html
November 01, 2023 - It is associated with adverse effects on physical and mental health.
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - comorbidities)
Patient Safety Indicators (PSIs)
Rates of potentially avoidable complications and adverse … mortality for pediatric surgical procedures
Rates of potentially avoidable complications and adverse … for Selected Procedures)
IQI 91 (Mortality for Selected Conditions)
PSI 90 (Patient Safety and Adverse … software
Further information about forthcoming updated ICD-9 PSI 90 composite (Patient Safety and Adverse … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - ___
Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-roster-2023dec.pdf
December 21, 2023 - Medical Officer
Name Department/Agency Title
Michael Lee, Pharm.D.,
BCPS, CAPT, USPHS
IHS IHS Adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/obesity_topic-refinement.pdf
May 22, 2014 - Adverse effects of interventions
● Activity-related injury
● Adverse effects of medication ( diarrhea … joint disease (i.e., knee, hip)
● Respiratory disease (i.e., asthma, COPD)
● Sleep apnea
o BMI
o Adverse … effects
● Activity-related injuries, including fracture
● Adverse effects of medications (e.g., diarrhea … later
● Among trials that report on clinical outcomes, for BMI, health-related quality of life,
and adverse
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/dental.html
March 01, 2014 - This communication failure results in an adverse event. … If given to a pregnant woman, this medication can have adverse effects on the fetus.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
April 01, 2023 - • 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. … Staff can use this decision tree when analyzing
an error or adverse event in an organization to help … Patient Safety Primer: Medication Errors and Adverse Drug Events
https://psnet.ahrq.gov/primers/primer … Patient Safety Primer: Medication Errors and Adverse Drug Events
23.
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pbrn.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Or a patient having wisdom teeth removed may have a strong adverse reaction to the sedation and require
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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.pdf
May 01, 2017 - This
principle calls for L&D unit teams to evaluate
their processes and learn from adverse
events, … 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:
o Unit data suggesting adverse events or
near misses that may have been
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pbrn.ahrq.gov/cpi/about/otherwebsites/PBRN/pbrn.html
September 01, 2018 - Field testing of a new ambulatory care electronic Medication Errors and Adverse Drug Events Reporting
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pbrn.ahrq.gov/diagnostic-safety/research/index.html
March 01, 2024 - Learning more about the link between diagnostic errors and outcomes, including adverse events.
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pbrn.ahrq.gov/news/blog/ahrqviews/comments-pso-draft-report.html
February 01, 2021 - Although we still see too many events such as adverse drug reactions, infections, or falls, momentum
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pbrn.ahrq.gov/talkingquality/explain/share-info/highlight.html
September 01, 2019 - For example, in the next few years, we may see systems that enable patients to report on adverse events
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pbrn.ahrq.gov/news/newsroom/press-releases/carbon-emissions.html
September 01, 2022 - Healthcare is both a significant contributor to climate change and responsible for managing the adverse
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
August 01, 2022 - management of patient safety events by implementing processes that facilitate full disclosure of an adverse