-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2023-virtual-research-meeting-summary-patient-experience.pdf
January 01, 2023 - Black
adults, compared to White adults, are more likely to report preventable adverse events. … However, compared to White adults, Black adults were 64
percent more likely to report an adverse event … Future research should seek to understand better ways to communicate that will, in
turn, prevent adverse … Patients
perceive that issues arise due to a combination of errors/adverse events and
communication … We make the case (a) that patient
14
safety surveys must inquire about all adverse events, not
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - Hilborne
Abstract
Physician reporting of adverse events and unsafe situations remains extremely … Each adverse event or near miss should be
viewed and used as a learning experience to better understand … Because adverse events usually
occur as a result of multiple failures, it is imperative that medical … Discussion
Traditional physician adverse event reporting behavior
Physicians traditionally use a … Reasons
for not reporting adverse incidents: an empirical study.
-
www.ahrq.gov/patient-safety/reports/hotline/summary.html
May 01, 2016 - out by the Institute of Medicine, 2 and the AHRQ Common Formats, a which includes definitions of adverse … events and forms for adverse event reporting. … any relevant information collected from other sources within their organizations (such as an existing adverse … the identified goals (patient safety improvement, public monitoring and accountability, research on adverse … Overall, the number of consumer reports was disappointing, given the potential reservoir of adverse events
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.docx
January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8.
Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … The costs and savings associated with prevention of adverse events by critical care nurses. … allows users to track the change in rate of any type of adverse event over time.
-
www.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Older adults have a high prevalence of chronic pain and are especially vulnerable to adverse events from … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
August 25, 2015 - An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO:
Explain the diagram to others, and ask others to provide examples of adverse events that are not … Implementing change is hard work, particularly when the change involves a response to an adverse patient
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.pdf
October 01, 2016 - The
adverse consequences of unnecessary antibiotic use include adverse drug reactions or
interactions
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.docx
October 01, 2016 - The adverse consequences of unnecessary antibiotic use include adverse drug reactions or interactions
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
May 05, 2008 - Meliones MD, MS
Abstract
Background: During the analyses of adverse events, a commonly described … This temporary fix
is commonly referred to as a “workaround.”9, 10
During the analyses of adverse … Understanding adverse events: Human
factors. Qual Health Care 1995; 4: 80-89.
5. Reason J. … The nature of
adverse events in hospitalized patients. … Understanding and responding to adverse
events. N Engl J Med 2003; 348: 1051-1056.
16.
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
January 01, 2021 - For example, Medication or Other Substance events that were reported as
Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction
in patient … For example, Medication or Other Substance events that were reported as Adverse reaction
in patient … For example, Medication or Other Substance events that were reported as Adverse reaction
in patient … For example, Medication or
Other Substance events that were reported as Adverse reaction in patient
-
www.ahrq.gov/sites/default/files/2024-02/gurses-report.pdf
January 01, 2024 - In the US, adverse drug events (ADEs) in community settings accounted
for 2.5-11.2% of all emergency … A theoretical framework of risks and hazards for medication-related adverse events.
Table 1. … Care transitions pose high risk for adverse drug
events. … National
surveillance of emergency department visits for outpatient adverse drug events. … Risk factors for hospital
admissions associated with adverse drug events.
-
www.ahrq.gov/hai/universal-icu-decolonization/index.html
September 01, 2013 - Safety and Adverse Events
The REDUCE MRSA Trial (Randomized Evaluation of Decolonization … Safety and Adverse Events
Authors
University of California Irvine
Susan Huang, MD, MPH
Adrijana
-
www.ahrq.gov/es/patient-safety/settings/hospital/match/references.html
July 01, 2022 - The costs of adverse drug events in hospitalized patients. … Adverse Drug Events Prevention Study Group. JAMA 1997; 277(4):307-11. … Identifying hospital admissions due to adverse drug events using a computer-based monitor.
-
www.ahrq.gov/patient-safety/settings/hospital/match/references.html
July 01, 2022 - The costs of adverse drug events in hospitalized patients. … Adverse Drug Events Prevention Study Group. JAMA 1997; 277(4):307-11. … Identifying hospital admissions due to adverse drug events using a computer-based monitor.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - regarding the definition of true postoperative respiratory failure,
it still remains an important patient adverse … at increased risk for postoperative respiratory failure
to better prepare clinicians to anticipate adverse … Decreased central nervous system input (head injury, ingestion of central nervous system
depressant, adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4m_combo_psi18-19-obstetriclaceration-bestpractices.pdf
May 20, 2016 - Patients and families may resort to legal action in order to
offset the financial burden of an obstetric adverse … responsibilities.2
Effectiveness of Action Items
• Identify perinatal quality improvement and obstetrical adverse … Define and routinely monitor and analyze your hospital’s perinatal quality measure and
obstetrical adverse … comprehensive-program-virtually-eliminates-
preventable-birth-trauma
Tools
• How-To Guide: Prevent Obstetrical Adverse
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - regarding the definition of true postoperative respiratory failure,
it still remains an important patient adverse … at increased risk for postoperative respiratory failure
to better prepare clinicians to anticipate adverse … Decreased central nervous system input (head injury, ingestion of central nervous system
depressant, adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
-
www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology ( PDF , 109 KB ) … Voluntary Adverse Event Reporting in Rural Hospitals ( PDF , 478 KB )
Charles P. … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance … News Media and Health Care Providers at the Crossroads of Medical Adverse Events ( PDF , 129 KB ) … Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency
-
www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
January 01, 2024 - not previously noted in preoperative evaluation or self-reported as pre-existing,
were qualifying adverse … Any exacerbation of preoperative hearing changes was
reported as an adverse event as well. … In addition, patients were screened for adverse events,
including hearing loss and local or systemic … If either an infection or an
adverse event of any kind was suspected per checklist criteria, the site … Similar statistical analyses were performed to assess secondary outcomes, safety outcomes,
adverse events
-
www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
January 01, 2024 - Scope and Significance
Preventable Adverse Drug Events in Community Pharmacies
Adverse drug events (ADEs … The cost of adverse drug events in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events.
Implications for prevention. … Adverse drug events in hospitalized patients. … Adverse drug events in ambulatory care.