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Total Results: 2,230 records

Showing results for "adverse".

181. 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

182. 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.

183. 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.

184. 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.

185. 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

186. 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

187. 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.

188. 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?        

189. 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

190. 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

191. 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.

192. 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.

193. 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.

194. Section 7C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
     June 02, 2025 - Table VII.C.1 – Distribution of insurance types and adverse … 58.2%) 0.10 <0.001 No Insurance 102 (3.2%) 0.04 0.001 Table VII.C.2 – Analysis of differences in adverse

195. 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

196. 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

197. Understanding Omissions of Care in Nursing Homes | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/omissions.html
     October 01, 2019 - Understanding Omissions of Care in Nursing Homes Adverse events and poor health outcomes

198. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Were there adverse effects? What was the impact on quality of life? … Relationship between medication errors and adverse drug events. … Incidence of adverse events and negligence in hospitalized patients. … Computer adverse drug event (ADE) detection and alerts. … The clinical pharmacist’s role in preventing adverse drug events.

199. Table 7.A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
     June 02, 2025 - Table VII.A.1 – Distribution of race/ethnicity and adverse … Hispanic 352 (12.4%) 0.18 <0.001 Other 161 (5.7%) 0.12 0.12 Table VII.A.2 – Analysis of differences in adverse

200. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - enrich clinicians’ understanding of patient and family experience and reduce the harms that follow adverse … Although patient and family conceptions of adverse events do not always conform to clinical definitions … diagnostic errors, it is important to identify and understand the broader scope of patient-defined adverse