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441. Chapter 6. Track Performance with Metrics | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide6.html
     May 01, 2016 - having significant drops in hemoglobin while on anticoagulation can spur chart review to determine if an adverse … drug event occurred, to assess the level of harm, and to examine the case for error. 20 An approach … reviewed for a list of "triggers" for further review. 21 Triggers potentially related to anticoagulant adverse … drug events (ADEs), such as an elevated INR, elevated PTT, use of anticoagulant reversal agents, change

442. Strategy 4: IDEA Discharge Planning (Tool 4)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
     April 01, 2011 - within a month of discharge, of which ¾ could be prevented Common complications post-discharge are adverse … drug events, hospital-acquired infections, and procedural complications Many complications can be attributed … these events could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, healthcare-associated infections, and procedural complications.

443. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
     January 01, 2025 - Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995; 274: 35-43. 10.

444. 009-Antibiotic-Stewardship-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/009-antibiotic-stewardship-guide.docx
     October 01, 2024 - AHRQ Safety Program for MRSA Prevention Antibiotic Stewardship and MRSA Reduction ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Antibiotic Stewardship and MRSA Reduction SAY: Welcome to this presentation on antibiotic stewardship as part of an overall approach to preventing MRSA in ICU and non-IC…

445. Final Progress Report: Diagnostic Error in Dystonia (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
     January 01, 2025 - Final Progress Report: Diagnostic Error in Dystonia 5R01HS018413-02 REVISED Tanner CM I FINAL PROGRESS REPORT Project Title: Principal Investigator: Team Members: Project Dates: Federal Project Officer: Acknowledgment of Agency Support and Grant Number: DIAGNOSTIC ERROR IN DYSTONIA Tanner, Caroline M., MD, …

446. Paul Tedrick (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-transcript.doc
     June 10, 2014 - In 2008, we looked at data on outpatient visits to emergency departments for adverse drug events related … presented to an emergency room, and the attending clinician who saw them in the ER thought that they had an adverse … drug event attributed to antibiotics. … percentage of those were unnecessary, there’s opportunities to prevent emergency department visits for adverse … drug events because many of these patients were probably getting antibiotics that they maybe didn’t

447. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - Moreover, Thomas et al. (2000) found that adverse drug events account for up to 19% of adverse events

448. Behavioral Health Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0085-fullreport.pdf
     December 31, 2015 - Behavioral Health Risk Assessment Behavioral Health Risk Assessment Section 1. Basic Measure Information 1.A. Measure Name Behavioral Health Risk Assessment 1.B. Measure Number 0085 1.C. Measure Description Please provide a non-technical description of the measure that conveys what it measures to a broad …

449. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - Additional methods include a telephone hotline for the reporting of adverse drug events and retrospective

450. Involving Patients and Families in Safety: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/involving-patients-families-in-safety-slides.pdf
     July 25, 2023 - nursing homes which addresses safety -- antibiotic stewardship, infection prevention, telehealth Adverse … Drug Events Part of our Medicare Quality Innovation Network- Quality Improvement Organization program

451. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - Improving the Value of Patient Safety Reporting Systems Improving the Value of Patient Safety Reporting Systems Peter J. Pronovost, MD, PhD; Laura L. Morlock, PhD; J. Bryan Sexton, PhD; Marlene R. Miller, MD, MSc; Christine G. Holzmueller, BLA; David A. Thompson, DNSc, MS; Lisa H. Lubomski, PhD; Albert W. Wu, M…

452. Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship (June 10, 2014) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/mindfulness-transcript.html
     December 01, 2017 - In 2008, we looked at data on outpatient visits to emergency departments for adverse drug events related … presented to an emergency room, and the attending clinician who saw them in the ER thought that they had an adverse … drug event attributed to antibiotics. … percentage of those were unnecessary, there's opportunities to prevent emergency department visits for adverse … drug events because many of these patients were probably getting antibiotics that they maybe didn't

453. Final Progress Report: Midcoast Maine Patient Safety and IT Integration (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
     January 01, 2024 - Measures  FTE per Occupied Bed  Paid Hours per Adjusted Discharge  Expense per Adjusted Discharge Adverse … Drug Events (ADE) • Unreconciled medications per 100 admissions • Percent of unreconciled medications … Guidelines for falls, medication errors and adverse drug reactions are in place, and double signatures

454. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - time the medication was reviewed by pharmacy; whether there was a medication error or subsequent adverse … drug reaction (ADR); indication for medication administered; and whether the nurse scanned the medication

455. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
     January 01, 2024 - Final Progress Report: Putting a Face on Hospital Medical Errors: Communication FINAL REPORT Putting a Face on Hospital Medical Errors: Communication Project funded by: Agency for Healthcare Research and Quality Grant No. 1R03HS016122-01 September 29, 2005-September 30, 2006 Federal Project Officer: Elizabeth D…

456. Maternal and Child Health Care: Care Coordination Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/mchcare-measures.html
     June 01, 2018 - Chartbook on Healthy Living Maternal and Child Health Care: Care Coordination Measures Previous Page Next Page Table of Contents Chartbook on Healthy Living Acknowledgments Healthy Living Summary Healthy Living Measures Maternal and Child Health Care Maternal and Child Health Care: Eff…

457. Strategy 4: IDEA Discharge Planning (Implementation Handbook) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
     April 01, 2011 - Common complications post-discharge include adverse drug events, hospital-acquired infections, and procedural … Patients prescribed high-risk medications or complex medication regimens may be at higher risk of adverse … drug events.4,6,8 Inadequate preparation for discharge.

458. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/summary.html
     August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Chapter 2. Conceptual Framework and Design Chapter 3. Description …

459. Final Progress Report: EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/vaughan-report.pdf
     January 01, 2024 - SCOPE Background: Older adults are a vulnerable population at high risk for medication adverse drug events

460. Chartbook on Women's Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
     March 01, 2020 - Adverse drug events occur in 15% or more of older patients presenting to offices, hospitals, and extended … Importance: Adverse effects of medical care can arise from medical and surgical procedures as well as from adverse … drug reactions. … Reducing the risk of adverse drug events in older adults.