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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Care
Need for Change
Nine percent of all births in the United States involve serious obstetrical adverse … For more than a decade, poor teamwork and communication have remained the leading
causes of maternal adverse … Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Newborns
The goal of the AHRQ Safety Program for Perinatal Care is to decrease maternal and neonatal
adverse … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury)
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
April 01, 2011 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … Nearly 20 percent of patients experience an adverse event within a month of discharge, of which ¾ could … be prevented
Common complications post-discharge are adverse drug events, hospital-acquired infections … these events could have been prevented or ameliorated.1
Common post-discharge complications include adverse … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/874.html
August 01, 2023 - available to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse … Articles featured this week include:
Anticoagulation-associated adverse drug events in hospitalized
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/872.html
July 01, 2023 - process can enrich clinicians’ understanding of patient and family experience and reduce harms following adverse … emergency departments to provide nonemergency care to residents, potentially placing residents at risk of adverse
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/878.html
August 01, 2023 - (Source: JAMA Network Open , Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem … include:
Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality … Risk factors for opioid-related adverse drug events among older adults after hospitalization for major
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www.cpsi.ahrq.gov/questions/resources/glossary.html
November 01, 2020 - Top of Page
M
Medical Error: An unintended but preventable adverse effect of care, whether or … Morbidity also refers to adverse effects caused by a treatment.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/health-literacy/3rd-edition-toolkit/assessment-quiz.docx
March 01, 2024 - Bad OR Adverse
b. Hypertension OR High Blood Pressure
c. Blood Glucose OR Blood Sugar
d.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
April 12, 2018 - .
■ Answer your questions.
1 in 9
emergency
department admissions
are related to an
adverse drug
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Management in this facility seems interested in patient safety only after an adverse event happens
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www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/index.html
July 01, 2023 - improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse
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www.cpsi.ahrq.gov/teamstepps-program/resources/additional/labor.html
July 01, 2023 - techniques used in labor and delivery units can help improve communication and collaboration and reduce adverse
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www.cpsi.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.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
March 01, 2016 - Staff can use this decision tree when analyzing an error or
adverse event in an organization to help … a multidisciplinary team approach, known as Root
Cause Analysis (RCA) to study health care-related adverse … Sorry
http://www.nhsla.com/Claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf
Although victims of adverse … presents the principles of a just culture, a nonpunitive
environment that encourages reporting of adverse … /psnet.ahrq.gov/primers/primer/23
A growing evidence base supports specific strategies to prevent adverse
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
November 18, 2019 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or
adverse events … Management in this facility seems interested in patient safety only
after an adverse event happens
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www.cpsi.ahrq.gov/research/findings/studies/index.html?page=480
January 01, 2024 - 1279)
2015
(1430)
2014
(662)
2013
(195)
Topics
Access to Care
(417)
Adverse … Drug Events (ADE)
(321)
Adverse Events
(736)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Opioids, Medication, Substance Abuse, Screening, Adverse Drug Events (ADE), Adverse Events
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www.cpsi.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.cpsi.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
December 01, 2023 - Readmissions
High rates of readmissions are a major patient safety problem associated with adverse
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www.cpsi.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - for Ambulatory Surgery
6
Studies show that communication failures are the cause of 80 percent of adverse … for the entire team
Cards were placed in every operating room
Reduced wrong-site surgeries and other adverse … Ensures all team members are on the same page
Confirms critical information
Provides a place to discuss adverse … or potentially adverse events that occurred
Facilitates discussion of how to stop problems from reoccurring