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www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
January 01, 2024 - Incidence of adverse drug events and
potential adverse drug events: Implications for prevention. … Adverse drug reactions: A critical review. JAMA. 1975
1975;234:1236-1241.
14. … Systems analysis of adverse drug events.
JAMA. 1995;274:35-43.
15.
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www.ahrq.gov/sites/default/files/2024-02/king-report.pdf
January 01, 2024 - Final Progress Report: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF)
Project Title: Management of Direct Anticoagulants to Lower Adverse Events in Atrial Fibrillation (MODL-AF)
Grant Number: 5R18HS026156-04 Project/Grant Period: 08-01/2018-05/31/2022
Principal Investig…
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www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
January 01, 2024 - The costs of adverse drug events in hospitalized patients. JAMA
1997;277(4):307-311.
6. … Systems analysis of adverse drug events. JAMA 1995;274(1):35-43.
7.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
January 01, 2004 - of all medication orders, and only a fraction of these errors cause harm
to patients in the form of adverse … drug events (ADEs).8–10 Leape, et al5 point out
that it would be “incredibly difficult to mount a controlled … Cognitive
activities include consideration of the patient's condition and history, as well as
possible drug … side effects and interactions. … Systems
analysis of adverse drug events. JAMA 1995 (274):35-
43.
37. Flynn EA, Barker KN.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - Using MPSMS data, AHRQ determined that national efforts to reduce hospital-acquired conditions such
as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion
between 2014
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www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
January 01, 2024 - Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery
Developing a patient-centered model of the risk of perioperative complications in spine surgery
John Ratliff, MD, PI
Team members:
Summer Han, PhD
Richard Olshen, PhD
Lu Tian, PhD
Paola Suarez
…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/diagnostic-safety-workgroupmeeting-notes-july2022.pdf.pdf
November 03, 2022 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
July Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that “A…
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
January 01, 2023 - patient)
• Near fall – loss of balance that does not result in a fall
Medication or Other Substance
• Adverse … drug reaction with no apparent incorrect action
• Patient food (not suspected in drug-food interactions … decision to
prescribe medication despite known drug-drug interaction)
• Drug-drug, drug-food, or adverse … drug reaction as a result of a prescription and/or
administration of a drug and/or food prior to admission
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-quickstart-final508.pdf
June 02, 2025 - implementors and use them
as peer coaches.
6 Evaluate your progress
Evaluate effectiveness
� How many adverse … drug events occur pre-
and post-implementation?
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - Safe Medication Administration: Slide Presentation
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Safe Medication Administration
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Define high-alert medications.
Identif…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
October 01, 2017 - Final Topic Refinement Document: Home Mechanical Ventilators
Final Topic Refinement Document
Home Mechanical Ventilators
ID: PULT0717
Agency for Healthcare Research and Quality
Technology Assessment Program
Mayo Clinic Evidence-based Practice Center
16 October 2017
Preliminary Key Questions (KQs) …
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www.ahrq.gov/research/findings/final-reports/index.html?page=0
September 01, 2024 - Empirical Evaluation of Labels Designed to Provide Older Users the Information They Need to Minimize Adverse … Drug Events ( application/pdf 777583 ) Principal Investigators: Becker and Bix Grant Number: R01
-
www.ahrq.gov/sites/default/files/2024-07/cox-carayon-report.pdf
January 01, 2024 - The most
common medication topics raised by families were scheduling (24%) and adverse drug reactions … Adverse drug events, defined as harm
resulting from use, nonuse, or misuse of medication, occur in 14% … of pediatric outpatients receiving a
prescription.55 The majority of preventable adverse drug events … These changes typically addressed either adverse drug events or families’
concerns about the scheduling … Risk factors in preventable adverse drug events in
pediatric outpatients.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
April 02, 2020 - Lessons
from a patient partnership intervention to prevent adverse drug events. … Consensus building for
development of outpatient adverse drug event triggers. … Computerized surveillance of adverse drug events
in hospital patients. … Overview of the First Natural Language Processing Challenge
for Extracting Medication, Indication, and Adverse … Drug Events From Electronic Health Record
Notes (MADE 1.0).
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
April 02, 2020 - Lessons
from a patient partnership intervention to prevent adverse drug events. … Consensus building for
development of outpatient adverse drug event triggers. … Computerized surveillance of adverse drug events
in hospital patients. … Overview of the First Natural Language Processing Challenge
for Extracting Medication, Indication, and Adverse … Drug Events From Electronic Health Record
Notes (MADE 1.0).
-
www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: The Science of Improving Patient Safety and Identifying Defects
Say:
The topic of this module is the science of patient safety. The discussion will include the importance of unders…
-
www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
January 01, 2024 - In a study of ADEs in a 700-bed
hospital, adverse drug events (ADEs) and preventable ADEs were estimated
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
January 01, 2005 - Systems
analysis of adverse drug events. ADE Prevention
Study Group. … Incidence of
adverse drug events and potential adverse drug events.
Implications for prevention.
-
www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-ref.html
September 01, 2015 - Reducing the risk of adverse drug events in older adults.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
April 01, 2025 - Patient Safety Primer: Medication Errors and Adverse Drug Events
https://psnet.ahrq.gov/primers/primer … /23
A growing evidence base supports specific strategies to prevent adverse drug events (ADEs). … Training Catalog
Patient Safety Essentials Toolkit: Huddles
Patient Safety Primer: Medication Errors and Adverse … Drug Events
Person-Centered Care
Plan-Do-Study-Act (PDSA) Steps Worksheet
Pioneer Network Resource … Patient Safety Primer: Medication Errors and Adverse Drug Events
18. Person-Centered Care
19.