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Showing results for "adverse event".
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1301. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
      June 01, 2013 - The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes … to establish the final definition below: Patient safety is the prevention and amelioration of adverse … AIR assumes that in the event that the catalog is maintained on the PSNet, the PSNet webmaster will … - or Robotic-Assisted Surgery 0 665 ---- Computer-Assisted Radiotherapy 0 661 -- Computerized Adverse … Event Detection 6 667 -- Telemedicine 0 691 Driving Change 56 692 Risk Analysis 114 693 Triage

1302. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - Keywords: Adverse drug events, Medical Records Systems, Computerized Ambulatory Care Information Systems … , Adverse Drug Reaction Reporting Systems, Ambulatory care, Medication errors, Medical errors, Quality … bi-weekly) expert panel meetings • Participated in conference calls • Analyzed indicators of errors or adverse

1303. Primary-Care-Based-Efforts (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/primary-care-based-efforts.pdf
      March 01, 2019 - setting.44 The period after discharge for patients is a critical time when changes in medications, adverse … They identified drug therapy problems, including inappropriate medications, adverse reactions, difficulty … Addressing post-discharge adverse events: a neglected area. … Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital … The incidence and severity of adverse events affecting patients after discharge from the hospital.

1304. Primarycareeffortstoreducereadmissions-Envscan (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/PrimaryCareEffortsToReduceReadmissions-envscan.pdf
      March 01, 2020 - setting.44 The period after discharge for patients is a critical time when changes in medications, adverse … They identified drug therapy problems, including inappropriate medications, adverse reactions, difficulty … Addressing post-discharge adverse events: a neglected area. … Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital … The incidence and severity of adverse events affecting patients after discharge from the hospital.

1305. 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%

1306. 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%

1307. 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

1308. Biosketches | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
      September 01, 2016 - by Becker’s Health Review "Top 50" list) and originated Patient Safety Awareness Week in 2002, an event … for health care safety and quality in a variety of fields, including patient engagement, response to adverse … Safety Monitoring System, a nationwide surveillance project aimed at identifying the rates of specific adverse … paper, and led the AHRQ-Brigham medication safety HIT CERT CEDAR (Calling for Earlier Detection of Adverse

1309. 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.

1310. Improving Perioperative Patient Safety Through the Use of Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-StJacques_105.pdf
      March 29, 2008 - complexity and, unfortunately, are a source of a significant percentage of patient safety-related adverse … machine were within 3 feet of each other for more than 15 minutes, a software application would note the event … The nature of adverse events in hospitalized patients.

1311. AHRQ Strategic Plan for Health System Transformation To Optimize Health, Functional Status, and Well-Being Among Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/priority-populations/aging-well-strategic-plan.pdf
      August 01, 2024 - frequently receive fragmented and sub-optimal care, leading to poor outcomes, including avoidable adverse … recorded in medical records, such as medication prescriptions and laboratory test results, to generate adverse … event rates and trend performance over time. … It is designed to served as a local hospital and health system tool to identify and measure adverse … effectiveness of a novel patient-centered approach, assigning care coordinators to older patients at risk for adverse

1312. 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.

1313. 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.

1314. Appendix B. Decisionmaking and Readiness for Implementation | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apb.html
      September 01, 2013 - Safety and Adverse Events Assessing the Quality of the Evidence There are several factors … To avoid having persistent bacteremia count as multiple events, allow only one event per patient.

1315. Appendix B. Decisionmaking and Readiness for Implementation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apb.html
      September 01, 2013 - Safety and Adverse Events Assessing the Quality of the Evidence There are several factors … To avoid having persistent bacteremia count as multiple events, allow only one event per patient.

1316. 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.

1317. 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

1318. 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

1319. 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.

1320. 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.