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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
October 01, 2024 - Slide 1
Educational Objectives
SAY:
This presentation will discuss the harm and adverse outcomes associated … methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), are associated with adverse … microorganisms occur in the natural flora of the skin, intestines, and other organs, and do not cause adverse … MRSA infection occurs when MRSA on or in a patient’s body begins to cause invasive disease or adverse … Slide 28
Key Takeaways
SAY:
In conclusion, MRSA infections are associated with many adverse outcomes
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www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apa.html
September 01, 2013 - Safety and Adverse Events
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/001-ss-antimicrobial-prophylaxis-1-fg.docx
April 01, 2025 - Antimicrobial prophylaxis should also produce no adverse effects for the patient and have no adverse … antimicrobial agent should be safe and should be administered for the shortest effective period to minimize adverse … Doing this minimizes adverse side effects, minimizes the development of antimicrobial resistance, and … To reduce the risk of infusion-related adverse drug reactions, vancomycin should be infused over 60 minutes
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www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
February 01, 2017 - whether your patients were evaluated by a physical or occupational therapist, and finally, whether any adverse … Slide 29: Events
Say:
The next columns are designed to help track any adverse events that might … Slide 30: Event Codes
Say:
If no adverse events occurred, use "0" (the code for "none") to indicate … that no adverse events took place. … and the percentage of patients achieving their RASS or SAS target, as well as determine the top 10 adverse
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-5-attach-1.pdf
January 01, 2009 - therapy requires a higher level of family involvement,
whereas methylphenidate has some potential adverse … As was identified in the previous guideline, the most common stimulant adverse effects
are appetite … An uncommon additional significant adverse effect of
stimulants is the occurrence of hallucinations … For the
nonstimulant alpha-2–adrenergic agonists extended-release guanfacine and clonidine, adverse … with behavior therapy alone;
Concerns about whether the effects of medication on growth and other adverse
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
January 01, 2017 - Mobility in the ICU ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
Safety3
No serious adverse … Early Mobility in the ICU ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
Adverse Events4 … 9 patients had 14 adverse events (<1% of activities)
Falls to knees without injury (5)
Systolic blood … 0.70-1.06)
Fifty percent reduction in accidental extubation requiring reintubation
No documented adverse … in the ICU ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
25
Conclusions – Safety
Adverse
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www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
December 01, 2017 - cutting contextual factor
Moderates effectiveness of patient safety interventions
Associated with adverse … Negative Correlation: HSOPS and Patient Safety Events 5
Higher HSOPS scores are associated with fewer adverse … Beliefs, behaviors reflect organizational ability to learn
Associated with adverse events, patient … Exploring relationships between hospital patient safety culture and adverse events. … Leape, L.L. (2002) Reporting adverse events.
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
June 02, 2025 - Cancer-Free
Survival
Outcomes Similar at 5 and 10 Years
Whole Breast
Irradiation (WBI) Acute
Adverse
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
November 29, 2004 - The magnitude of adverse events related to medical errors in outpatient
chronic disease care is often … stroke preceded by uncontrolled chronic diseases, and each
associated premature death, represents an adverse … Incidence
and preventability of adverse drug events among older
persons in the ambulatory setting. … Adverse drug
events in ambulatory care. N Engl J Med. 2003 Apr
17;348(16):1,556–64.
9. … Detecting
adverse events using information technology.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
March 21, 2008 - Among a sample of elderly patients, Gurwitz, et al.,6 found
that many adverse drug events were due to … If
undetected, an error might require additional effort to resolve an adverse event. … Adverse drug
events in ambulatory care. N Engl J Med 2003; 348:
1556-1564.
3. … Incidence
and preventability of adverse drug events among older
persons in the ambulatory setting. … Classification of medical errors
and preventable adverse events in primary care: A
synthesis of the
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www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
March 11, 2022 - Indian Health
Service
• Enhanced Adverse Event Reporting Capabilities:
o Reporting of adverse events
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www.ahrq.gov/patient-safety/reports/engage/interventions/medmanage-slides.html
May 01, 2017 - Adverse drug events result in as many as 4.5 million ambulatory visits each year. 1
Medication reconciliation … improves patient safety and reduces adverse drug events:
prescribing errors, medication contraindications … Adverse drug events in U.S. adult ambulatory medical care.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/ref.html
June 01, 2010 - Rosenthal J, Takach M. 2007 Guide to State adverse event reporting systems. … As used in this report, the term "serious reportable adverse health event" is defined as an event that … The term is used broadly to encompass the terms "critical incidents," "sentinel events," and "adverse
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-facilitator-guide.pdf
November 01, 2019 - Targets
Slide Title and Commentary Slide Number and Slide
How Can You Identify Antibiotic-
Associated Adverse … from a
diverse group of health care workers about issues that
have resulted in antibiotic-associated adverse … events or
had the potential to cause adverse events that could
jeopardize patient safety. … Four Moments each time an antibiotic
course is prescribed is one example of an antibiotic-
associated adverse … In fact, the analysis shows that overall,
patients were spared from adverse events associated
with
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
June 16, 2008 - goal of the project is to use the
medical error ontology to identify strategies for preventing future adverse … The ultimate goal of
the project is to identify strategies for improvement to prevent future adverse … • Capture the richness of the domain of errors and adverse events. … Conclusions
and Future Work
A critical step in the direction of reducing errors and adverse events … MEDWATCH - The FDA Safety Information
and Adverse Event Reporting Program.
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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.pptx
May 01, 2017 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … Fetal Monitoring
12
Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse … episode involving an abnormal fetal tracing
Disclosing any unintended outcomes using unit policy for adverse … Past adverse events related to EFM use
Synergy with related or similar initiatives
Interest and enthusiasm
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-implementation-guide.pdf
January 01, 2018 - o CR reduces mortality over 1-3 years after a cardiac event
o CR reduces re- hospitalization and adverse … multiple chronic
conditions, diabetes, depression, mental stress and improves quality of life after an adverse … Ways to Reduce
Barrier/Opposition
Clinical
manager
-Improving
patient health
-Reducing
adverse … implementation
Generally, CR has a high return
on investment given improved
patient health, and reduced
adverse
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www.ahrq.gov/nursing-home/resources/search.html?page=13
January 01, 2022 - Vaccine Adverse Event Reporting System Reporting Form This webpage hosts a writable PDF form that provides … instructions for reporting a vaccine adverse event.
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www.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Her team found that 10 percent of children with leukemia or lymphoma experienced adverse drug events
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - Slide 28: Communicating Adverse Events
Say:
Communication following an adverse event can been especially … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … Slide 30: How To Communicate About An Adverse Event
Say:
It is important to remember that residents … and family members can experience a number of emotions when an adverse event occurs, so communication … about an adverse event should be compassionate and sensitive.