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381. Final Progress Report: Off-Label Prescribing: Comparative Evidence, Regulation, and Utilization (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kesselheim-report.pdf
     January 01, 2024 - Final Progress Report: Off-Label Prescribing: Comparative Evidence, Regulation, and Utilization PI Name: Aaron S. Kesselheim, M.D., J.D., M.P.H. Application ID: 5K08HS018465-05 Proposal Title: Off-label prescribing: Comparative evidence, regulation, and utilization Title: Off-label prescribing: Comparative evidence…

382. Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dierks-report.pdf
     January 01, 2024 - Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign 1P20HS017118-01 Meghan M. Dierks, MD Beth Israel Deaconess Medical Center Title of Project: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign Principal Investigator and Team …

383. AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Magnesium Sulfate (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
     May 30, 2013 - AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Magnesium Sulfate AHRQ Safety Program for Perinatal Care Safe Medication Administration Magnesium Sulfate Safe Medication Administration—Magnesium Sulfate Purpose of the tool: This tool describes the key perinatal safety elements with examples for…

384. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 15.

385. AHRQ-Funded Research Highlights Impact of Private Equity in Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/927.html
     August 01, 2024 - 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.

386. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Changing the System To Improve Patient Safety Long-Term Care Slide Title and Commentary Slide Number and Slide Changing the System To Improve Patient Safety SAY: Hello, and welcome to this presentation: “Changing the System To Improve Patient Safety.” Sl…

387. Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections – Slides
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-slides.pptx
     September 01, 2022 - Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections – Slides Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections Ambulatory Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(22)-0030 Sep…

388. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
     January 01, 2025 - Create processes for patient/family medication monitoring and communication with clinic to prevent adverse … drug events. … Adverse drug event: An injury resulting from medication use. … drug events similar to that of hospitalized children.2 An editorial about this study called for improved … Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive

389. Resources by Safety Topic | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/type-harm.html
     September 01, 2025 - Resources by Safety Topic Contents Diagnostic Safety Emergency Preparedness Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Diagnostic Safety AHRQ Diagnostic Steward…

390. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - Adverse Drug Events (ADEs), which can result from a medication error, occur at a rate of 2.4% to 4.6%

391. Final Progress Report: Improving Medication Management Practices and Care Transitions Through Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/feldman-report.pdf
     January 01, 2024 - Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting. … Field TS, Mazor KM, Briesacher B, et al., Adverse drug events resulting from patient errors in older

392. Many Pediatric Pneumonia Patients Receive Antibiotics Outside of Guidelines | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/967.html
     July 01, 2025 - Many Pediatric Pneumonia Patients Receive Antibiotics Outside of Guidelines Issue Number 967 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. July 22, 2025 Today’s Headlines: Many Pediatric Pneumonia Patients Receive Antibiotics Outside of Guidelines . Adult P…

393. Final Progress Report: Evaluating e-Prescribing in a Community-Based, Integrated Health System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/devine-report.pdf
     January 01, 2024 - research program, the evidence demonstrating the positive impact of CPOE systems on medication errors and adverse … drug events (ADEs) was largely limited to inpatient academic medical centers that had developed their … entry (CPOE) has been shown to improve patient safety by reducing medication errors and subsequent adverse … drug events (ADEs).

394. Data Reveal Uneven Impact of COVID-19 on Urban, Rural Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/913.html
     May 01, 2024 - Application of trigger tools for detecting adverse drug events in older people: a systematic review and

395. Strategy 4: IDEA Discharge Planning (Tool 1) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
     January 01, 2010 - three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications

396. About the Nursing Home Antimicrobial Stewardship Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/nhguide/about/index.html
     November 01, 2024 - About the Nursing Home Antimicrobial Stewardship Guide What Is the Nursing Home Antimicrobial Stewardship Guide? The Nursing Home Antimicrobial Stewardship Guide (the Guide) provides toolkits to help nursing homes optimize their use of antibiotics. This page provides information about antimicrobial stewardshi…

397. Final Progress Report: Risk-Informed Clinical Network for Safe Pediatric Emergency Transfers (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods-report.pdf
     January 01, 2025 - Adverse drug events in ambulatory care. New England Journal of Medicine. … Medication errors and adverse drug events in pediatric inpatients.

398. Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Layde_34.pdf
     March 14, 2008 - Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial Peter M. Layde, MD, MSc; Linda N. Meurer…

399. Development of a Comprehensive Medical Error Ontology (pdf file)
     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 - Development of a Comprehensive Medical Error Ontology Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala, MS; Julie Brixey, RN, PhD; Todd R. Johnson, PhD; Vimla L. Patel, PhD; Jiajie Zhang, PhD; James P. Turley, RN, PhD Abstract A critical step towards reducing errors in health care …

400. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
     January 01, 2024 - voluntary reporting systems capture just 1% to 10% of all actual errors33,34 and just 1% to 5% of adverse … drug events.35 In addition to this low capture rate, comparisons of error rates generated from voluntary … Identifying adverse drug events: Development of a computer-based monitor and comparison with chart review … Computerized surveillance of adverse drug events in hospital patients. … Relationship between medication errors and adverse drug events.