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Showing results for "adverse event".
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1281. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-team-assessment-scale-jtcommjqualpatsaf.pdf
      June 30, 2024 - Team members have a systematic process in place to capture and learn from near misses and no-harm adverse … Most Commonly Reviewed Sentinel Event Types. (Updated: Feb 2, 2021.) … https://www.jointcommission.org/-/media/tjc/documents/ resources/patient- safety- topics/sentinel- event … / most- frequently- reviewed- event- types- 2020.pdf. 6. … /most-frequently-reviewed-event-types-2020.pdf http://refhub.elsevier.com/S1553-7250(23)00207-6/sbref0006

1282. Appendix B. Journal Articles Included in Literature Review | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/apcd/envscan/app-b.html
      June 01, 2017 - Investigation of adverse-event-related costs for patients with metastatic breast cancer in a real-world … Costs of adverse events among patients with HIV infection treated with nonnucleoside reverse transcriptase

1283. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
      April 01, 2022 - Slide 7 When making decisions about whether to culture urine in the event of a new fever in an adult … Perhaps the most obvious harms are allergies and adverse effects (like renal failure) from antibiotics … However, to improve retention, tell stories about adverse events so they feel real and personal to ICU

1284. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa2.pdf
      January 01, 2018 - replacement -12.31 0.0 0.014 MPSMS 8 (2009- 2016) Hospital patients with an anticoagulant-related adverse … drug event to low-molecular-weight heparin (LMWH) and factor Xa -11.33 0.0 0.00 MPSMS 8 (2009- 2016 … ) Inpatient adverse events in adults receiving hip joint replacement due to degenerative conditions … drug event with IV heparin in adult hospital patients who received an anticoagulant -6.08 0.0 0.014 … drug event to warfarin -2.74 0.028 0.366 MPSMS 8 (2009- 2016) Bloodstream infection in adult patients

1285. Improving Antibiotic Use is a Patient Safety Issue
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
      November 01, 2019 - Issue AHRQ Safety Program for Improving Antibiotic Use – Acute Care 5 5 Antibiotic-Associated Adverse … events3 ~25% of these patients developed antibiotic-associated adverse events after hospital discharge … Most adverse events had some clinical ramifications Additional hospitalizations (3%) Prolonged hospital … Approximately 20% of hospitalized patients develop antibiotic-associated adverse events. … Association of Adverse Events with Antibiotic Use in Hospitalized Patients.

1286. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
      March 01, 2016 - Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … a multidisciplinary team approach, known as Root Cause Analysis (RCA) to study health care-related adverse … Sorry http://www.nhsla.com/Claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf Although victims of adverse … medical event, developed a toolkit for clinician support.

1287. Voluntary Hospital Coalitions to Promote Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rask.pdf
      January 01, 2004 - PHA includes a voluntary and confidential event reporting system, organizational self-assessment programs … Event reporting system Providing a voluntary event reporting system was one of the main priorities … event reporting system. … When a hospital’s peer review contact reports an adverse event to PHA, he or she is guided through an … Reporting of adverse events. N Engl J Med 2002;347:1633–8.

1288. Making Health Care Safer II, Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
      March 01, 2013 - event rates from 2003 to 2008. … general, we addressed two issues: the frequency of the safety problem, and the severity of each average event … The scope must also consider the severity of each event; for instance, most falls do not result in injury … , and most potential adverse drug events do not result in clinical harm. … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090.

1289. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
      February 01, 2017 - Slide 11: Safety 3 No serious adverse events. … Slide 14: Adverse Events 4 9 patients had 14 adverse event (<1% of activities): Falls to knees … No documented adverse events. 6. Clark DE, Lowman JD, Griffin RL, et al. … Slide 26: Conclusions—Safety Adverse events ranged from agitation to transient physiological events … Adverse events ranged from 2.3 to 8.7 per 100 patients. 3-5 3.

1290. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
      June 02, 2025 - diagnostic errors were a chief concern in outpatient visits 1 in 9 ED admissions are related to an adverse … drug event An estimated 160 million medication errors occur each year in primary care 80%

1291. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/patient-safety-issues.pdf
      June 02, 2025 - diagnostic errors were a chief concern in outpatient visits 1 in 9 ED admissions are related to an adverse … drug event An estimated 160 million medication errors occur each year in primary care 80%

1292. AHRQ National Scorecard on Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/index.html
      July 01, 2020 - Condition Rate ( PDF , 237 KB) To improve how the Nation tracks its progress on reducing HACs and other adverse … This patient safety surveillance system will capture information about HACs and other adverse events

1293. Appendixes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/haccost2017-appendix.html
      November 01, 2017 - Drug Events (("Drug therapy/adverse effects"[mh] OR "drug interactions"[mh] OR "anaphylaxis"[mh] OR … "drug overdose"[mh] OR "Drug-related side effects and adverse reactions"[mh] OR "adverse drug event" … [tiab] OR "adverse drug events"[tiab] OR "adverse drug reaction"[tiab] OR "adverse drug reactions"[tiab … effects"[Mesh] OR "Central Venous Catheters/adverse effects"[mh] OR "Catheters, Indwelling/adverse effects … Clinical and economic impact of adverse drug reactions in hospitalized patients.

1294. Slide 1 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
      January 01, 2013 - event. … When an event is reported, it feels like the person is being written up, not the problem. … When an event is reported, it feels like the person is being written up, not the problem. … We are given feedback about changes put into place based on event reports. (C1) 2. … We are given feedback about changes put into place based on event reports. (C1) 62% 2.

1295. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
      September 01, 2023 - Healthcare providers submit patient safety event data to Patient Safety Organizations (PSOs), which … In addition, causal inferences cannot be based on these event data alone. … harm is defined as harm to the patient after discovery of the incident and any attempts to minimize adverse … associations between various concurrent reported event characteristics. … Does error and adverse event reporting by physicians and nurses differ? Jt. Comm. J. Qual.

1296. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
      November 01, 2019 - They can be associated with adverse events, and when administered to patients who do not need them, … Slide 4 Antibiotic-Associated Adverse Events SAY: All antibiotics have the potential to harm … Often, these adverse events occur after a patient is discharged from the hospital. … Overall, 20 percent of patients developed at least 1 antibiotic- associated adverse event. … Approximately 20 percent of hospitalized patients develop antibiotic-associated adverse events.

1297. Labor and Delivery Unit Safety: Shoulder Dystocia | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
      July 01, 2023 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … Learn From Defects (CUSP Element) Debrief and analyze near misses and adverse events related to … A unit can decide its approach to debriefing events based on seriousness of event, expertise available … Informal debriefings by clinical team immediately following event using an approach that does not shame … Shoulder dystocia training can be effective at reducing adverse outcomes. 6,9,10 A sample scenario

1298. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
      May 01, 2017 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … Defects (CUSP Element) Key Perinatal Safety Elements Examples Debrief and analyze near misses and adverse … · Informal debriefings by clinical team immediately following event using an approach that does not … www.safehealthcareforeverywoman.org · Resource name: Process for Reviewing Severe Maternal Morbidity Event … Sample scenario: · Shoulder dystocia · Shoulder dystocia training can be effective at reducing adverse

1299. Measure Descriptions for Daily Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-fac-guide.html
      February 01, 2017 - whether your patients were evaluated by a physical or occupational therapist, and finally, whether any adverse … Slide 29: Events Say: The next columns are designed to help track any adverse events that might … Slide 30: Event Codes Say: If no adverse events occurred, use "0" (the code for "none") to indicate … that no adverse events took place. … There are 25 event codes all together, ranging from endotracheal tube dislodgement to death.

1300. Risk-Based Patient Safety Metrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
      March 25, 2008 - Observer correctly attributes event as error. … event from recurring, rather than improving overall system safety. … Incidence of adverse events and negligence in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … Understanding adverse events: Human factors. Qual Health Care 1995; 4: 80-89. 14.