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www.ahrq.gov/patient-safety/reports/liability/corbett.html
August 01, 2017 - System in the Sanford Health System
Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … A recent study suggests that up to 23 percent of patients experienced an adverse event within 5 weeks … To emphasize the importance of eliminating the occurrence of adverse events and ADEs, several health … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Adverse drug reactions in older people. Rev Clin Gerontol 2010; 20(3):246-59.
18.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - Slide 4
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 … findings.
· Whether timely and appropriate clinical responses occur with respect to EFM findings.
· Past adverse
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-slides.html
May 01, 2017 - Fear of litigation
Transparency and adverse events, compliance with patient privacy laws. … Opportunities for Patient and Family Engagement in Your Facility
Disclosure and apology for unexpected adverse … 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/es/patient-safety/settings/hospital/red/toolkit/redtool1ref.html
March 01, 2025 - Adverse events in hospitals: overview of key issues. … Adverse events among medical patients after discharge from hospital. CMAJ 2004;170(3):345-9.
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool1ref.html
March 01, 2025 - Adverse events in hospitals: overview of key issues. … Adverse events among medical patients after discharge from hospital. CMAJ 2004;170(3):345-9.
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www.ahrq.gov/hai/pfp/interimhac2013-ap4.html
December 01, 2014 - 2014 Goal Met
Projected Reductions in Deaths Associated With HACs in 2014 if 2014 Goal Met
Adverse … Falls
200,000
25%
50%
12.5%
25,000
$7,234
.055
$180,850,000
1,375
Obstetric Adverse
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … Slide 13: Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse … Disclosing any unintended outcomes using unit policy for adverse events. … Past adverse events related to EFM use.
Synergy with related or similar initiatives.
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool-other.html
March 01, 2013 - Outcome measures include reduction in direct harm associated with adverse events and treatment misadventures … , including death, disability (permanent or temporary), adverse drug events, or preventable harm requiring … . 7 This document lists key measures of success in improving outcomes, including:
Reduction in adverse
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-other.html
March 01, 2013 - Outcome measures include reduction in direct harm associated with adverse events and treatment misadventures … , including death, disability (permanent or temporary), adverse drug events, or preventable harm requiring … . 7 This document lists key measures of success in improving outcomes, including:
Reduction in adverse
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www.ahrq.gov/antibiotic-use/acute-care/safety/changes.html
November 01, 2019 - decision making
Slides (PPTX)
Facilitator Guide (PDF)
Learning from Antibiotic–Associated Adverse
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www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
January 01, 2024 - The purpose of this study was to examine whether adverse events or
complications in hospitals occur … Several recent studies, as well as an IOM report, show an increase in mortality
and adverse events with … Relation between malpractice
claims and adverse events due to negligence. … Incidence of adverse events and
negligence in hospitalized patients. … Incidence of and risk factors for adverse
events and negligent care in Colorado and Utah in 1992.
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www.ahrq.gov/patient-safety/about/areas.html
February 01, 2018 - Team Training
Falls
Pressure Ulcers
Diagnostic Safety
Blood Clot Prevention and Treatment
Adverse
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www.ahrq.gov/teamstepps-program/resources/additional/sbar.html
July 01, 2023 - how this technique, one tool in the TeamSTEPPS training program, can improve communication, reduce adverse
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www.ahrq.gov/sites/default/files/2024-02/ornstein-report.pdf
January 01, 2024 - drug-drug interactions, avoiding potential drug-disease interactions, and
monitoring or prevention of adverse … inappropriate dosing, drug-drug interactions,
drug-disease interactions, and monitoring or prevention of adverse … drug-drug interactions, avoiding potential drug-disease interactions,
and monitoring or prevention of adverse … Monitoring/Preventing Potential Adverse Drug Events
• Annual serum creatinine monitoring for ACE inhibitor … Drug-Disease Interactions
Avoiding Potentially Inappropriate Therapy
Monitoring/Preventing Potential Adverse
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www.ahrq.gov/sites/default/files/2025-03/connors-report.pdf
January 01, 2025 - Adverse events were not uniformly defined and wide ranges of occurrence of adverse
events were described … How to define safety in terms of definitions of what constitutes an adverse event?
4
a. … If the patient experiences a brief monitored event but no lasting effects, is the
event adverse? … Does the magnitude of a monitored response change constitute an adverse event at
a particular level … Adverse sedation events in pediatrics: A critical
incident analysis of contributing factors.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pdf
July 01, 2004 - • The AHRQ QIs are a set of indicators for adverse events that
patients may experience as a result of … – Consider inserting here the deidentified story of a patient who
suffered the adverse event captured … You may also want to report the number of patients with the adverse event to make it
more tangible to … – Consider inserting here the deidentified story of a patient who suffered the adverse event captured
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
May 01, 2017 - Fear of Litigation
With patient privacy laws and the fear of oversharing information about adverse … If an adverse outcome occurs, take the following immediate steps:
Provide care for the patient – … Report to appropriate parties – Providers will use their facility’s policies to report adverse events … Communicate with the patient – Providers communicate by sharing relevant facts about an adverse event … , to Responding to Adverse Events).
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www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
July 01, 2025 - These adverse events are influenced by patient, provider, and practice factors. … Both the video laryngoscope and apneic oxygenation interventions resulted in reductions in adverse
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
August 01, 2022 - This video demonstrates an example of emotional support provided for the physician caregiver after an adverse
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/nurses.html
August 01, 2022 - This video demonstrates an example of emotional support provided for the nurse caregiver after an adverse