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261. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
     June 18, 2008 - monitoring helped clinicians identify opioid-associated respiratory depression and prevent a potential adverse … drug event. … response to opioid analgesics, even when correctly programmed, therapeutic doses can result in an adverse … drug event.2 While some patient populations are at higher risk of an opioid-related event, clinical

262. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - drug events, and ineffective communication and information flow. … Problems with medications: Adverse drug events (ADEs). … Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556-1564. 18. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … National surveillance of emergency department visits for outpatient adverse drug events.

263. I. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/intro1.html
     May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events I. Introduction Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events Pr…

264. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - initial ED evaluation that led to a missed diagnosis that was discovered by the subsequent shift; an adverse … drug event (allergic reaction); and a case in which definitive treatment was delayed because of a reported … Medication not available in ED 3 Ordering – delay or failure 2 Administration – delay or failure 2 Adverse … drug event 1 (1) Medication not available from pharmacy 1 Ordering – wrong dose 1 Ordering – wrong time

265. Final Progress Report: Patient Partnerships To Improve Safety in the Clinic Setting: Creating an accurate medication list through a patient-centered approach (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/leonhardt-report.pdf
     January 01, 2024 - drug events (ADEs). … drug events, or medication adherence. … 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;348:1556-1564 4. … National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events.

266. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis 323 Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair,…

267. Information to Help Hospitals Get Started
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pptx
     July 23, 2010 - within a month of discharge, of which ¾ could be prevented Common complications post-discharge are adverse … drug events, healthcare-associated infections, and procedural complications Many complications can be … these events could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, healthcare-associated infections, and procedural complications.

268. Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
     January 01, 2024 - Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis Title: Topical Vancomycin for Neurosurgery Wound Prophylaxis Principal Investigator: Connolly, Edward Sander Team Members: Jared Knopman, MD - Site PI (Cornell) Emilia Bagiella, PhD - Site PI (Mount Sinai) Franklin Lowy, MD - Co-Investigato…

269. Antibiotic Stewardship Program (ASP) Development
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-slides.pptx
     June 01, 2021 - Antibiotic Stewardship Program (ASP) Development Developing an Antibiotic Stewardship Program Long-Term Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(21)-0029 June 2021 Developing a Program 1 Objectives Name the goals of antibiotic stewardship and why it is important in long-term care (LT…

270. 10 Patient Safety Tips for Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
     June 01, 2018 - used incorrectly, blood thinners can cause uncontrollable bleeding and are among the top causes of adverse … drug events.

271. Patient Safety Research Summaries | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/research-summaries/index.html
     June 01, 2025 - safety refers to the practices and measures implemented to minimize the risk of medication errors and adverse … drug events in various settings across the healthcare continuum.

272. Final Progress Report: Addressing methodological and ethical issues in pediatric medication safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/carpenter-report.pdf
     January 01, 2024 - teams; ethical issues in pediatric drug development; measuring child-reported outcomes; and preventing adverse … drug events in pediatric populations. … Adverse Drug Reactions in Children: The Impact on Clinical Care and Prescribing Practices (Jennifer … Communication in Pharmacy Settings Speakers: Delesha Carpenter, Julia Gilmartin, Oksana Pyzik 13 4.38 0.65 Adverse … Drug Reactions in Children: The Impact on Clinical Care and Prescribing Practices Speaker: Jennifer

273. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home Carole Hemmelgarn Three

274. Information to Help Hospitals Get Started (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pdf
     June 02, 2025 - within a month of discharge, of which ¾ could be prevented • Common complications post-discharge are adverse … drug events, healthcare-associated infections, and procedural complications • Many complications

275. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
     January 01, 2024 - drug events. … One is entitled “The Effectiveness of Computerized Order Entry at Reducing Preventable Adverse Drug … Events and Medication Errors in Hospital Settings: A Systematic Review and Meta-Analysis is in press … drug events, pADEs). … Drug Events in Hospital Settings: A Systematic Review and Meta-Analysis.

276. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schillinger.pdf
     January 01, 2004 - drug events.2 Effective communication regarding medications can help avoid medication-related errors3 … drug events at rates disproportionate to its use,2 routinely identifying discordance and developing … drug events. … Adverse drug events in ambulatory care. N Engl J Med 2003;348(16):1556–64. 2. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

277. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
     January 01, 2024 - Testing of HAMMERS™ verified the accuracy of its estimates of preventable adverse drug events. … that combine and contribute to dispensing system failures and the overall incidence of preventable adverse … drug events. … Medication dispensing errors and potential adverse drug events before and after implementing bar code

278. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
     March 01, 2020 - Studies have found that IV infusion is associated with 54 percent of all adverse drug events, 56 percent … drug events. … drug events. … In addition, the number of adverse drug events more severe than level 2—defined as events that reach … drug events

279. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - human factors, error, harm, safety, systems PURPOSE In the United States, medication errors and adverse … drug events cost the average teaching hospital $5.6 million annually, half of which are thought to … Medication errors, critical incidents, adverse drug events, and more: a review examining patient safety-related

280. Create a Safe Medicine List Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
     June 02, 2025 - • Adverse drug events • Unsafe medicine issues • Medicine adherence • Satisfaction • Reported use … We will use several measures to evaluate effectiveness: How many adverse drug events occur pre- and