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Total Results: 2,263 records

Showing results for "adverse".

401. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … More than three-fourths of PSOs offered analytical support for adverse events, and a similar share … Analytic Support for Adverse Events. … Copyright 2015 ECRI Institute. www.ecri.org • Adverse events • Near misses • Hazards • Common Formats … Notably, they require all members wishing to submit information on an adverse event to their PSO to

402. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     December 01, 2017 - In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … can redesign care and delivery processes to improve care and minimize the occurrence of errors and adverse … shows the continuum of system factors that can influence health care delivery and the occurrence of adverse … This evaluation provides the means to identify interventions that can reduce the risk of future adverse

403. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - systems approach"[All Fields] OR "medical error*"[All Fields] OR "medical mistake*"[All Fields] OR "adverse … Diagnostic errors [mh] OR iatrogenic disease [mh] OR sentinel surveillance [mh] OR safety [mh] OR (adverse

404. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - Grant Award Number: 5U18HS011926-03 Abstract Purpose: Adverse events are among the nation’s most … Scope Preventable adverse patient events, including nosocomial or hospital-acquired infections and … The Institute of Medicine reports that adverse patient events are responsible for 44,000-98,000 deaths … Types of system failures that have been identified include inadequate adverse outcome reporting systems … Adverse Drug Events (ADEs), which can result from a medication error, occur at a rate of 2.4% to 4.6%

405. Patient Safety Research Summaries | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/research-summaries/index.html
     September 01, 2025 - It is a critical process for identifying improvement areas, standardizing care, preventing adverse events … safety refers to the practices and measures implemented to minimize the risk of medication errors and adverse

406. PowerPoint Presentation (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-UTI-slides.PPT
     June 01, 2021 - not associated with increased morbidity or mortality Unnecessary antibiotics are associated with: Adverse … Common Antibiotics Used To Treat UTIs2,3 11 Antibiotic Route Information About Antibiotic Most Common Adverse … analyze data using the Monthly Data Collection Form Introduce the Learning From Antibiotic-Associated Adverse … of Antibiotic Decision Making Form Monthly Data Collection Form Learning From Antibiotic-Associated Adverse

407. Care for the Caregiver Program Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
     August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … responsible for item or Action Plan Reporting Culture Are policies in place to support reporting adverse … YES  NO       Adverse Event Investigation Process Is an adverse event policy in place

408. Improving Patient Safety by Engaging Patients and Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
     April 30, 2025 - ■ A project demonstrated that hospitalized patients can provide useful information about adverse … and analyze an adverse event to learn from it and prevent future adverse events. • Review and revise … A study of the decision aids reduced the use of discretionary surgery without apparent adverse effects … Key Findings/Impact: Researchers documented the capacity of hospitalized patients to identify adverse … This project helped show that hospitalized patients can provide information about adverse events and

409. Final Progress Report: NYU Patient Imaging, Quality and Safety Laboratory (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/horwitz-report.pdf
     January 01, 2025 - We have conducted dozens of qualitative interviews, reviewed hundreds of adverse event reports, spent … Assessment of adverse events associated with peri-procedural handoffs We reviewed 375 adverse event … The most commonly reported adverse events were procedural complications (109, 29.1%), many of which … Adverse events associated with peri-procedural handoffs, under review. Oral presentations 1. … Trends in adverse events after IV administration of contrast media.

410. Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
     July 01, 2023 - Liability Say: Further, EFM interpretation and management is a common issue in litigation involving adverse … unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … Finally, unit staff should disclose any unintended outcomes related to EFM use using unit policy for adverse … Past adverse events related to EFM use.

411. TeamSTEPPS Research/Evidence Base: Labor and Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/evidence-base/labor.html
     May 01, 2023 - Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized … Impact of a comprehensive patient safety strategy on obstetric adverse events. 

412. Outcomes by HCBS Participant Characteristics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find5.html
     December 01, 2012 - Thus, while the overall HCBS indicators exhibit a general pattern of higher rates of adverse outcomes … may be attributable to effectiveness of care—HCBS participants who receive more services have fewer adverse … HCBS as a percentage of total long-term care spending ( Burwell, et al., 2006 ) have lower rates of adverse … States that are more supportive of HCBS extend services to healthier individuals, resulting in fewer adverse … indicator rates, with lower income and higher poverty consistently associated with higher rates of adverse

413. Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
     March 10, 2008 - These tools can be used to help hospitals identify potential adverse events that might need further … study and also to enable users to assess the occurrence of in-hospital adverse events using routinely … Adverse events among medical patients after discharge from hospital. … The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Knowledge translation and patient safety: The Canadian adverse events study.

414. Final Progress Report: Electronic Communications Across Provider Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/morrison-report.pdf
     January 01, 2024 - Information Technology (HIT) has proven links to improved quality of patient care and the reduction of adverse … Finally, a plan for measuring adverse drug events was created. … Repository Purpose HIT has proven links to improved quality of patient care and the reduction of adverse … Such systems have been shown to decrease the incidence of adverse medical events, facilitate communication … the “high-risk” drugs and drugs for which there is evidence- based consensus on surveillance labs or adverse

415. Many Pediatric Pneumonia Patients Receive Antibiotics Outside of Guidelines | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/967.html
     July 01, 2025 - A level 1 trauma center and safety net hospital, Harborview uses QIs to review adverse events and integrate … makes use of Patient Safety Indicators (PSIs), a subset of QIs that target in-hospital safety issues—adverse … Using QIs has also improved Harborview’s rating in the Patient Safety and Adverse Events Composite (

416. Intramuscular Injections – Best Practices for Safe Vaccine Administration in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
     June 01, 2021 - assess pulse • Oxygen • Pulse oximeter • Access to a phone to call 911 If a resident has an adverse … reaction after vaccination, nursing home staff should review the Vaccine Adverse Event Reporting System … Name and title of person who administered the vaccine • Vaccine route and site • Dosage in mL • Any adverse

417. Final Progress Report: Labor and Delivery Nurse Staffing: A Patient Safety Intervention (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/wilson-report.pdf
     January 01, 2024 - Purpose: To determine if a relationship exists between labor and delivery (L&D) nurse staffing and adverse … Scope: Numerous studies indicate a relationship between nurse staffing and adverse outcomes for medical … Because adverse events are linked to staffing levels, they are often referred to as ‘nurse sensitive … Just as hospital- acquired pressure ulcers constitute an adverse hospital event and are sensitive to … SCOPE Numerous studies have identified a relationship between nurse staffing levels and adverse outcomes

418. Understand the Science of Safety Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
     July 01, 2018 - 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.

419. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-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. … An alternative strategy for studying adverse events in medical care.

420. Private Sector Efforts in Value-Based Purchasing and Quality Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-measures/21st-century/private-sector.html
     June 01, 2018 - Incidence of adverse drug events and potential adverse drug events: implications for prevention. … The costs of adverse drug events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice … Breakthrough Series Guide: Reducing Adverse Drug Events . … Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction.