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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-Clarke_8.pdf
January 25, 2008 - Adverse drug reaction (not a medication error)
C. Equipment, supplies, and/or devices
D. … to the intentional sampling of a set
number of reports from each event type, some of which (e.g., adverse … drug reactions and
complications) always presume harm.
11
• The analysts may have had a bias
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
January 01, 2019 - drug event to low-molecular-weight
heparin (LMWH) and factor Xa (MPSMS)
3.5% in 2014 1.7% in 2017 … -21.9 0.008
Medication Safety Adverse drug event with IV heparin in adult hospital
patients who received … 2014 1.1% in 2017 -13.1 0.113
Medication Safety Hospital patients with an anticoagulant-related
adverse … drug event to warfarin (MPSMS)
4.8% in 2014 3.7% in 2017 -12.1 0.298
Medication Safety Hospital … patients who received a hypoglycemic
agent who had an adverse drug event with a
hypoglycemic agent
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www.ahrq.gov/es/topics/index.html?page=1
January 01, 2012 - Topics
Information on AHRQ's most-searched topics are included below and in the A to Z menu above. Results
Topics 11 - 19 of 19 displayed
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Health Literacy Health literacy occurs when health information and serv…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
February 24, 2008 - Preventing adverse drug events. Am J
Health Syst Pharm 1995; 52: 379-382.
6. Leape LL. … Pharmacist
participation on physician rounds and adverse drug
events in the intensive care unit.
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - Strategies to Better Engineer Safety into Healthcare Delivery
Page 1 of 17
Engineering Safe Practices Affinity Group
Strategies to Better Engineer Safety into
Healthcare Delivery
March 6, 2025
Table of Contents
Problem Statement ...............................................................................…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors
Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods
Previous Page Next Page
Table of Contents
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
September 01, 2024 - Adverse drug events from medication can often mimic acute medical conditions in older adults, thus contributing … and a “prescribing cascade,” where a second, potentially unnecessary drug is prescribed to treat the adverse … drug event.
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www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
May 01, 2024 - drug events in ambulatory care settings. … California, San Francisco; School of Medicine, Family Medicine Develops a tool for patients to report adverse … drug events (ADEs) to their ambulatory care teams. … California, San Francisco; School of Medicine, Family Medicine Develops a tool for patients to report adverse … drug events (ADEs) to their ambulatory care teams.
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www.ahrq.gov/research/findings/final-reports/index.html?page=8
January 01, 2024 - Factors, Risk Assessment Publication Date: April 2015
Enhancing the Detection and Management of Adverse … Drug Events in the Nursing Home ( application/pdf 787663 ) Principal Investigators: Handler, et
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
August 01, 2022 - discrepancies collected in this previous study to determine the potential for discrepancies to result in an adverse … drug event (ADE), the severity of the ADE (i.e., serious, significant, minor), the potential health
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
July 01, 2023 - Safe Medication Administration: Magnesium Sulfate
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements with examples for the safe administration of magnesium sulfate during labor. The key elements are presented within the framework of t…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/ncepcr-older-adults-presentation.pptx
March 15, 2025 - Approaches to Address Health Risks for Older Adults
National Center for Excellence in Primary Care
1
National Center for Excellence in Primary Care Research
Presents
Approaches to Address Health Risks for Older Adults
January 16, 2025
Presented by:
Lisa Kern, MD, MPH
Alberta K. Tran, Ph.D., RN, CCRN
Yu-J…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Safe Medication Administration
Safe Medication Administration
SAY:
The Safe Medication Administration bundle provides information on high-alert medications commonly used in labor and delivery (L&D) units, and discusses the importance of implementing safeguards for their administ…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-fac-guide.html
July 01, 2023 - Safe Medication Administration: Facilitator Guide
AHRQ Safety Program for Perinatal Care
Slide 1: Safe Medication Administration
Say:
The Safe Medication Administration bundle provides information on high-alert medications commonly used in labor and delivery (L&D) units, and discusses the importance of …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/004-ss-antimicrobial-prophylaxis-part-2.pptx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI
Antimicrobial Perioperative Prophylaxis: Part 2
Beyond the Basics
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. No. 25-0029
April 2025
AHRQ Safety Pro…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/antibiotic-stewardship/abx-stewardship-part2.pptx
March 01, 2017 - Antibiotic Stewardship Slides, Part 2
Antibiotic Stewardship
AHRQ Pub. No. 16(17)-0003-22-EF
March 2017
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Welcome to today’s educational session on antibiotic stewardship. This module is part of the Agency for Healthcare Research and Quality (or AHRQ) Safety Progra…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
March 05, 2008 - Impact of Staff-Led Safety Walk Rounds
Impact of Staff-Led Safety Walk Rounds
Vicki L. Montgomery, MD, FAAP, FCCM
Abstract
Objectives: The primary objectives of this study were to provide a venue for discussing safety
concerns and to facilitate finding solutions for everyday safety issues. Methods: The
mul…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/carnahan.pdf
January 01, 2014 - Improving Antipsychotic Appropriateness in Dementia Patients
…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/healthit-ed-4.html
February 01, 2021 - Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments
Health Applications for Synchronous and Asynchronous Communication
Previous Page Next Page
Table of Contents
Health Information Technology for Engaging Patients in Diagnostic Decision Making in…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-datasources.pdf
December 31, 2021 - MPSMS is composed of 21 measures representing six types of adverse drug events (ADEs); six
types of … Data Sources 84
Measure
Primary
Domain Data Period
ADE - IV Heparin Adverse drug
events
2004 … -2007 and
2009-2019
ADE - Low Molecular Weight Heparin Adverse drug
events
2004-2007 and
2009- … 2019
ADE - Warfarin Adverse drug
events
2004-2007 and
2009-2019
Catheter-Associated Urinary Tract … Adverse drug events among hospitalized Medicare patients:
epidemiology and national estimates from a