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Showing results for "adverse".

161. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     June 02, 2025 - improve communication among patients, families, and clinicians; and · Discuss how to communicate an adverse … Medical providers are committed to caring for their patients; however, adverse events can happen. … Immediately after an adverse event, care providers: · Provide care. … Slide 25 SAY: Adverse events are often system failures. … Rarely does an adverse event occur as a result of intent.

162. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
     January 01, 2025 - Scope: TI is a life-saving procedure; however, it is often associated with adverse outcomes in PICUs … Our preliminary single-PICU data documented adverse TI-associated events (TIAEs) occur among >20%. … Discussion: Adverse TI events were common across diverse pediatric ICUs. … We currently are evaluating the impact of this project with targeted outcomes: adverse TIAEs. … Association of vagolytic and ketamine use with tracheal associated adverse events.

163. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Near-miss reporting systems have many potential benefits over adverse event detection systems. … “Near-miss” Reporting: Implications for Human Protection 189 Adverse event example. … to and management of the adverse event would have likely been less timely. … Systems analysis of adverse drug events. ADE Prevention Study Group. … Reporting of adverse events. N Engl J Med 2002;347(20):1633–8. 39.

164. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - The objective of this initial conversation is to advise the patient and/or family that an adverse event … Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation.

165. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - Key Words: adverse events, emergency department, trigger tool 3. … event,” “adverse reaction,” and “taxonomy.” … Adverse events related to emergency department care: a systematic review. … Performance of the adverse drug event trigger tool and the global trigger tool for identifying adverse … A trigger tool to identify adverse events in the intensive care unit.

166. EvidenceNOW: Managing Unhealthy Alcohol Use Webinar | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/projects/alcohol/webinar-uau-evaluation.html
     August 01, 2024 - As a leading cause of preventable death, UAU is associated with a wide range of adverse consequences

167. Pf-Engagement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
     May 01, 2017 - Discuss how to communicate an adverse event to patients and family members. … Immediately after an adverse event, care providers: Provide care. … Slide 21 SAY: Adverse events are often system failures. … Rarely does an adverse event occur as a result of intent. … Organizations need to engage in strategies to address adverse events.

168. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … interim 2014 16,760 7,922 4,403 2,750 22 42,716 1,748 1,150 1,768 7,429 Adverse … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent

169. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were … Events Associated With Hip Joint Replacements 19,000 0.59 MPSMS (2014) Adverse Events Associated

170. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
     November 19, 2015 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … $45,000,000 $10,030,000,000 $1,302,000,000 $168,000,000 $136,000,000 $2,788,000,000 Adverse … (Journal of Patient Safety, in press) indicated that in 2012 and 2013, adverse events were less frequent

171. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
     December 01, 2016 - has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure … Healthcare Cost and Utilization Project. 39.6% 16.1% 1.1%2.4% 0.9% 27.9% 2.8% 0.4% 0.8% 8.1% Adverse … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … (see https://www.ncbi.nlm.nih.gov/pubmed/26854418) indicated that in 2012 and 2013, adverse events were

172. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
     August 01, 2022 - program should expect to implement a number of leading practices to improve communication and response to adverse … In the short term, hospitals will develop processes to improve the reporting and monitoring of adverse … events and promote better care for patients through candid, caring communication in the wake of an adverse … and to promote better care for patients through candid, caring communication in the wake of an adverse … event (see Adverse Event (Reasonable Care) and Adverse Event (Unreasonable Care)) .

173. Candor-Impguide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
     April 01, 2016 - should expect to implement a number of leading practices to improve communication and response to adverse … Recent research shows a significant correlation between the frequency of adverse events and malpractice … It also emphasizes the organization’s commitment to improve the reporting and monitoring of adverse … event (see Adverse Event [Reasonable Care] and Adverse Event [Unreasonable Care]). … event • Number of adverse events reported >24 hours after occurrence – Severity level of adverse

174. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - Medical Care Visits Due to Adverse Effects of Medical Care Adult ambulatory medical care visits due … to adverse effects of medical care per 1,000 population, by race, stratified by sex, United States, … Importance: Adverse effects of medical care can arise from medical and surgical procedures as well … as from adverse drug reactions. … Providers treating adverse events in outpatient settings may include office-based physicians, hospital

175. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017.html
     November 01, 2017 - additional inpatient mortality associated with 10 selected hospital-acquired conditions (HACs): Adverse … Obstetric Adverse Events. Pressure Ulcers. Surgical Site Infections. … Extraction and Harmonization      Meta-Analysis Results      HAC Specific Considerations          Adverse … Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/or … We scrutinized cost and mortality definitions for their applicability to “in-hospital” adverse events

176. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
     June 01, 2023 - Expanding the scope to also include “problems” encourages reporting of adverse events where patients … The focus of questions is on the immediate antecedents and outcomes of the adverse event. … Given the uncertainties inherent in diagnosis, a portion of adverse diagnostic events that are not … The literature on medical errors documents that the long-term harms associated with adverse events are … Exacerbated harms associated with the adverse event.

177. Data Measures Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
     January 01, 2017 - event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur. … event occur Target Low adverse event rate Mobility NOT Intubated: Distribution of Adverse Events … event (5) occur, o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 … have adverse event (20) occur.

178. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
     www.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?

179. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
     September 01, 2017 - The reports: Focus on preventing adverse events. Are proactive rather than reactive. … These questions explore what the facility does to screen for risk of an adverse event. … The goal is to focus on preventing adverse events. … Improve root cause analyses when adverse events occur. … Discussion questions are tailored to the On-Time adverse event being addressed.

180. Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
     December 01, 2014 - Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse … 9,200 0.28 Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse … Femoral Artery Puncture for Catheter Angiographic Procedures 59,000 1.8 MPSMS (2013) Adverse … Events Associated With Hip Joint Replacements 21,000 0.63 MPSMS (2013) Adverse Events Associated