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Total Results: 2,263 records

Showing results for "adverse".

181. 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.

182. 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?

183. 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.

184. 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

185. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
     January 01, 2019 - the same 28 measures of patient safety events, including many types of hospital-acquired infections, adverse … For example, measured adverse drug events continued to drop from 2014 to 2017, while measured pressure … Preliminary 2017 2019 Goal (20% Reduction of each HAC) Adverse Drug Events 33.7 30.0 27.1 … National number of adverse events captured by PSIs 18 and 19 on obstetric injury and national number … Due to changes in how some conditions and adverse events are described in ICD-9 and ICD-10, the data

186. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
     August 01, 2022 - institutions include how to: Engage patients and families in disclosure communication following adverse … 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.

187. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - Nursing home staff generally do a good job of investigating and following up after an adverse event, … 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. … Improve root cause analyses when adverse events occur. … Discussion questions are tailored to the On-Time adverse event of interest.

188. AHRQ-Funded Patient Safety Highlights: Improving Healthcare Safety by Supporting Measure Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
     August 01, 2025 - and identification of adverse events across various healthcare settings. … Events: Provided actionable insights into adverse events (e.g., medication adverse events, diagnostic … • Most product-related adverse events are reported to the FDA by manufacturers. … Primary video laryngoscope use was significantly associated with lower adverse TIAEs. … events those reported adverse events.

189. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … Human,” as reported from the 2010 Medicare data: 13.5% of hospitalized beneficiaries experienced an adverse … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … As we saw in the “Do No Harm” Video, families reported how the silence they experienced after the adverse … Patients are looking for the actions the organization is doing to prevent and learn from the adverse

190. Module 4: Teamwork and Communication | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
     March 01, 2017 - Events Adverse event: An injury to a resident caused by medical intervention rather than by the … Prompt, compassionate, and honest communication with the resident and family after an adverse event is … Slide 29: Disclosure and Apology for Unexpected Adverse Outcomes Immediate Response to an Adverse … Event Next Steps in Responding to an Adverse Event Care for the resident. … Slide 30: How To Communicate About An Adverse Event Speak slowly and use clear language.

191. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - safety has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The MPSMS methodology to identify adverse events within each chart is identical to prior years. … It should be noted that for every year from 2010 to 2014, the VTE adverse events contributed less than … indicated that in 2012 and 2013, adverse events were less frequent at hospitals that had implemented

192. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - Compared to other industries, medicine has a relatively high rate of serious errors and adverse events … Accordingly, efforts to link individual fatigue to adverse outcomes has been difficult. … Errors with little or no potential for harm are not serious errors, nor are nonpreventable adverse … Either can lead to increased error and adverse event rates. … No adverse events occurred.

193. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.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?        

194. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
     June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … MPSMS Femoral Artery Puncture for Catheter Angiographic Procedures 57,000 1.75 65,000 1.97 MPSMS Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated

195. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - Measuring errors and adverse events. … events to study rates of serious medical errors and adverse events. … Detection of Errors and Adverse Events. … events, or adverse events; this step is ongoing. … Potential adverse events and adverse events are being rated on severity using a four-point Likert scale

196. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse … The realization that adverse events often occur because of system breakdowns, not simply because of … Transparency and Learning The idea that adverse events could yield information was not new, but as it … The goal of the field of patient safety is to minimize adverse events and eliminate preventable harm … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 15.

197. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features The QSRS: Offers an expanded array of adverse event measures.

198. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Human Services’ Office of the Inspector General, states that “patients may be experiencing unnecessary adverse … Of the preventable adverse drug events in nursing homes, 70 percent occurred at the monitoring stage … The Flow Records contain specific MDS items that may indicate adverse medication effects associated … Epidemiology of adverse drug events in the nursing home setting. Drugs Aging 1995;7:203–11. 17. … Incidence and preventability of adverse drug events in nursing homes.

199. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
     November 01, 2017 - Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/ … adverse events as the end point. … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[ … effects"[Mesh] OR “Central Venous Catheters/adverse effects”[mh] OR “Catheters, Indwelling/adverse

200. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
     November 01, 2017 - Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/ … adverse events as the end point. … “drug overdose”[mh] OR “Drug-related side effects and adverse reactions”[mh] OR “adverse drug event … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[ … effects"[Mesh] OR “Central Venous Catheters/adverse effects”[mh] OR “Catheters, Indwelling/adverse