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1321. Emergency Departments Don’t Coordinate How They Collect, Use Social Needs Information | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/918.html
      June 01, 2024 - Incidence of drug-related adverse events related to the use of high-alert drugs: a systematic review

1322. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4e_pdi06-heartsurgery-bestpractices.pdf
      May 16, 2016 - Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality

1323. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4s_combo_pdi06-heartsurgery-bestpractices.pdf
      May 16, 2016 - Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality

1324. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
      January 01, 2025 - Older ED patients are more likely to experience adverse outcomes after an ED visit compared with younger … should do next to ensure they receive the care they need and reduce their risk of a patient safety event … What is known about adverse events in older medical hospital inpatients? … Scale, nature, preventability and causes of adverse events in hospitalised older patients. … Safety analysis over time: Seven major changes to adverse event investigation.

1325. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/discussion-guide.docx
      March 01, 2017 - Moreover, these survey results are useful for measuring organizational conditions that can lead to adverse

1326. Library of PCOR Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/pcor/library-of-resources/index.html
      April 01, 2021 - database , which contains information on study participants and a summary of study outcomes, including adverse

1327. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
      May 01, 2017 - L&D Unit Safety 30 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … Factors to consider: Unit and malpractice claims data suggesting adverse events or near misses related

1328. 133-Translating-Research-Into-Practice-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/133-translating-research-into-practice-fg.docx
      April 01, 2025 - are shown to be more effective, leading to better health outcomes, reduced complications, and fewer adverse

1329. Final Progress Report: Creating Safe Ambulatory Care: The Path to Resilience (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/nemeth-report.pdf
      January 01, 2025 - Critical incident study collected information on reported adverse events in the work setting. … ambulatory care is the threat to patient well-being that can come from either commission (e.g., an adverse … event) or omission (e.g., denial, delay, partial care).

1330. The “Never Antibiotic” Diagnoses: Acute Bronchitis – Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/bronchitis-guide.docx
      September 01, 2022 - While antibiotics do not help with cough, they can put patients at risk for adverse events that may necessitate

1331. 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.

1332. Final Progress Report: Medication Management at Home: Patient-Identified Processes and Risk Assessment (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
      January 01, 2024 - medication management risks that occur within the healthcare system, relatively little is known about adverse … about medication management: 1) the desire for more information from providers; 2) concerns about adverse … Another study used root cause analysis to diagram patients’ views of the causes of adverse drug events … potential risk, and at other times they learn about the risk only after a significant life-changing event … Sacred Heart Foundation 4th Annual Clinical Research Recognition Event, 2009 October 13; Eugene, OR.

1333. 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.

1334. Final Progress Report: Improving patient safety through leadership and team performance in simulations (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/fernandez-report.pdf
      January 01, 2024 - cardiac arrest management protocols, there remain significant rates of medical error and preventable adverse … focus group interviews conducted with nurse and physician experts, (2) critical incident reviews of adverse … The key components of the measurement infrastructure included (1) a standardized event- based scenario … resuscitation team performance, and failures in leadership are responsible for a significant percentage of adverse

1335. Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities (pdf file)
      www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf
      March 09, 2008 - priorities among rural hospital administrators and patient safety staff, falls were listed second, after adverse … interviewed the patient, the staff, and any member of the patient’s family who might have witnessed the event

1336. Outpatient Surgery and Patient Safety—The Patient’s Voice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Hundt.pdf
      January 01, 2003 - Using computerized data to identify adverse drug events in outpatients. … Detecting adverse events for patient safety research: a review of current methodologies. … The incidence and severity of adverse events affecting patients after discharge from the hospital.

1337. Appendix A: Tools and Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/appa.html
      July 01, 2018 - bleeding. 13-15 More than 20 percent of patients with hospital-associated VTE will suffer a recurrent event … secondary to pharmacologic prophylaxis in patients with limited bleeding risk factors is a relatively rare event … 25 Good evidence reveals that pharmacologic VTE prophylaxis for at-risk patients not only prevents adverse … There are removable IVC filters, which could conceivably reduce long-term adverse events—but even these

1338. Appendix A: Tools and Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/appa.html
      July 01, 2018 - bleeding. 13-15 More than 20 percent of patients with hospital-associated VTE will suffer a recurrent event … secondary to pharmacologic prophylaxis in patients with limited bleeding risk factors is a relatively rare event … 25 Good evidence reveals that pharmacologic VTE prophylaxis for at-risk patients not only prevents adverse … There are removable IVC filters, which could conceivably reduce long-term adverse events—but even these

1339. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool5.html
      March 01, 2025 - Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse … drug event, or other symptoms may include: Providing patient education.

1340. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
      March 01, 2025 - Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse … drug event, or other symptoms may include: Providing patient education.