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www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
April 01, 2018 - Thromboembolism
0
414
Medication Safety
126
416
-- Medication Errors/Preventable Adverse … Ordering/Prescribing Errors
6
418
---- Transcription Errors
5
415
-- Side Effects/Adverse … Robotic-Assisted Surgery
0
665
---- Computer-Assisted Radiotherapy
0
661
-- Computerized Adverse
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www.ahrq.gov/funding/grantee-profiles/grtprofile-grigoryan.html
November 01, 2024 - inappropriately—for instance, not finishing all doses prescribed—leads to increased antibiotic resistance and adverse … Many had been unaware of any negative effects, such as antibiotic resistance and adverse drug reactions
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … Comparing patient-reported hospital adverse events with medical record review: do patients know something … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review … Health care complaints and adverse events as a means of user involvement for quality and safety improvement
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - primary care teams should consider individual patients’ risk factors for developing postdischarge
adverse … If left
unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … facilitating the implementation of these elements is important to enhance patient
safety since the risk of adverse … new approach primary care teams can use to engage
patients and families to help reduce postdischarge adverse
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-final-es.pdf
September 01, 2019 - Patient Safety
Importance of Patient Safety
Mortality
Prevalence
Cost
Findings on Patient Safety
Adverse … Events With Knee Replacement
Adverse Events With Hip Replacement
Adverse Drug Events With Heparin … Fibrinolytic Medication for Heart Attack
Disparities for Asians
Largest Disparities
Anticoagulant-Related Adverse
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form
Changing the System
12
What Happened? … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.
… Completion Guide for the Four Moments of Antibiotic Decision Making Form
Learning From Antibiotic-Associated Adverse
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www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html
April 01, 2021 - The PIQs Lab assessed adverse event reports related to VIR over a 6-year period, finding that 45 percent … The most commonly reported adverse events were procedural complications (109; 29.1%), many of which had … Adverse events associated with peri-procedural handoffs, under review.
2020
Garry K, et al.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-metabolic-monitoring-testing-summary.pdf
December 31, 2015 - Antipsychotics are associated with potentially adverse
metabolic impacts that include weight gain, … psychiatric disorders in children, these medications are associated with a
number of potentially adverse … Fiscal Burden
Although there is little research available on the fiscal burden associated with adverse
-
www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
January 01, 2024 - HHC patients may be
at risk of adverse events caused by medical management or medical errors as well … as from adverse events related to
household hazards. … Household hazards can result in adverse outcomes. … Incidence and Preventability of Adverse Drug Events in Hospitalized Adults. … Adverse health effects among adults exposed to home dampness and molds.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - risk” will go on to develop MCC
• Targeted interventions to improve health and reduce the
risk of adverse … interventions for those who have complex
management issues and who are at “high risk” for
avoidable adverse
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Escobar.pdf
February 01, 2005 - Reasons
for not reporting adverse incidents: an empirical study. … Incidence of
adverse drug events and potential adverse drug events.
Implications for prevention. … Incidence of
adverse events and negligent care in hospitalized
patients. … The nature of
adverse events in hospitalized patients. … Systems
analysis of adverse drug events. ADE Prevention
Study Group.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
January 01, 2004 - Unfortunately, a small portion of errors do result in an
“adverse event”—an injury caused by medical … We have since come to
realize that preventable medical deaths and adverse events happen in Wisconsin … of a facility with its equipment and technology lower or eliminate
preventable medical errors and adverse … Second, designing for patient safety will help to eliminate near-miss
incidents, errors, and adverse … Systems
analysis of adverse drug events. JAMA
1995;288:501–13.
3. Borden S. U.S.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-slide-set.pptx
May 01, 2017 - PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events). … Organizations should be prepared to respond and communicate proactively when adverse events occur. … PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events).
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
October 01, 2017 - of life
(QoL), activities of daily living (ADL), dyspnea, sleep quality, exercise tolerance, and adverse … emergency room visits,
disease exacerbations, QoL,
ADL, dyspnea, sleep quality,
exercise tolerance, and adverse … (KQ 5)
Adverse
Events
using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … life (QoL)
• Activities of daily living (ADL)
• Dyspnea
• Sleep quality
• Exercise tolerance
• Adverse
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - can redesign care and delivery processes to improve care and minimize the occurrence of errors and adverse … checklists, and create independent checks for key processes, we improve our ability to reduce the risks of adverse … Adverse event reporting systems are common in hospitals. … Slide 16
Staff Safety Assessment
SAY:
Adverse reporting systems, sentinel events, and claims data
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
March 01, 2009 - suffer a medication error2
On average, every patient admitted to an intensive care unit suffers an adverse … Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34. … An alternative strategy for studying adverse events in medical care.
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www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
July 01, 2018 - suffer a medication error. 2
On average, every patient admitted to an intensive care unit suffers an adverse … Incidence of adverse drug events and potential adverse drug events. JAMA . 1995;274(1):29-34.
3. … An alternative strategy for studying adverse events in medical care. Lancet . 349:309-313,1997.
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - Regulators and accreditors encourage health
care organizations to adopt “safe practices”
and to avoid adverse … 100
hospitalizations as “common;” examples include falls,
venous thromboembolism (VTE), potential adverse … Practices Designed for a Specific Patient Safety Target
Adverse Drug Events
High-alert drugs: patient … ‘Global trigger tool’
shows that adverse events in hospitals may be ten times
greater than previously … Adverse Events in Hospitals: National
Incidence
Among Medicare Beneficiaries. OEI-06-09-00090.
-
www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
January 01, 2024 - Medication errors, including preventable adverse drug events, are especially common in the
inpatient … In contrast to nonpreventable
adverse drug reactions (due to the inherent properties of the agent … A computer alert system to
prevent injury from adverse drug events: development and evaluation in a … In the prediction of adverse medication outcomes based on daily DHST data, our objective is to
temporally … Although most of the adverse drug events that occur during the
study period will be linked to a specific
-
www.ahrq.gov/patient-safety/reports/liability/preface.html
August 01, 2017 - System in the Sanford Health System
Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives
Medication Discrepancies and Potential Adverse