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1381. Appendix E. Training and Educational Materials (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape4.html
      September 01, 2013 - Safety and Adverse Events Protocol Training, Part 1: Mupirocin Background 2% Topical

1382. AHRQ's Health Services Research Dissertation Grant Program: New Starts, Fiscal Year 2012 | Agency for Healthcare Research and Quality
      www.ahrq.gov/funding/training-grants/grants/active/dissrt12/dissrt12.html
      October 01, 2014 - research project will contribute to a technology-based, multifaceted approach for reducing inpatient adverse

1383. Strategy 2: Communicating for Improve Quality (Tool 6) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_6_Pres_TX_508.pdf
      June 02, 2025 - Research shows patient-centered communication can improve: – Patient safety • More than 70 percent of adverse

1384. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
      June 01, 2023 - voicemail-based signout did not change patient outcomes such as intensive care unit (ICU) transfers or perceived adverse

1385. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-slides-final508.pptx
      June 02, 2025 - Miscommunication and omissions can lead to medical errors and adverse events.

1386. Warm Handoff Plus (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-slides-final508.pdf
      June 02, 2025 - Miscommunication and omissions can lead to medical errors and adverse events.

1387. Recommendations and Areas for Future Research | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses4.html
      August 01, 2022 - physician by presenting a case and receiving feedback. 42 The study reported a significant reduction in adverse

1388. HF Measures For Public Comment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternitycare.pdf
      February 23, 2012 - The Work Group also aimed to develop an outcome measure assessing adverse events during birth. … (USPSTF 2009) Alcohol and substance abuse in pregnant women have been linked to a variety of adverse … Adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal … Because of the potential adverse consequences of prenatal alcohol exposure, short screening … Measure Importance Relationship to desired outcome Maternal obesity is associated with adverse

1389. HF Measures For Public Comment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0082maternity.pdf
      February 23, 2012 - The Work Group also aimed to develop an outcome measure assessing adverse events during birth. … (USPSTF 2009) Alcohol and substance abuse in pregnant women have been linked to a variety of adverse … Adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal … Because of the potential adverse consequences of prenatal alcohol exposure, short screening … Measure Importance Relationship to desired outcome Maternal obesity is associated with adverse

1390. Maternity Care Performance Measurement Set (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf
      February 23, 2012 - The Work Group also aimed to develop an outcome measure assessing adverse events during birth. … (USPSTF 2009) Alcohol and substance abuse in pregnant women have been linked to a variety of adverse … Adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal … Because of the potential adverse consequences of prenatal alcohol exposure, short screening … Measure Importance Relationship to desired outcome Maternal obesity is associated with adverse

1391. HF Measures For Public Comment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0084maternity.pdf
      February 23, 2012 - The Work Group also aimed to develop an outcome measure assessing adverse events during birth. … (USPSTF 2009) Alcohol and substance abuse in pregnant women have been linked to a variety of adverse … Adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal … Because of the potential adverse consequences of prenatal alcohol exposure, short screening … Measure Importance Relationship to desired outcome Maternal obesity is associated with adverse

1392. HF Measures For Public Comment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
      February 23, 2012 - The Work Group also aimed to develop an outcome measure assessing adverse events during birth. … (USPSTF 2009) Alcohol and substance abuse in pregnant women have been linked to a variety of adverse … Adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal … Because of the potential adverse consequences of prenatal alcohol exposure, short screening … Measure Importance Relationship to desired outcome Maternal obesity is associated with adverse

1393. Six Building Blocks How-To-Implement Toolkit: Prepare and Launch Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-prepare.pdf
      February 18, 2021 - For instance, the champion could share a story of an adverse outcome—such as overdose, death, or diversion—for … • List of opioid names. • List of sedative names. • Tracking and monitoring example spreadsheet. • Event … attribution.xlsx https://familymedicine.uw.edu/improvingopioidcare/wp-content/uploads/sites/9/2020/10/Event-Tally … For instance, you could use the event tally form to track a measure of interest over the course of … Kickoff-Manual_w-attribution.pdf https://familymedicine.uw.edu/improvingopioidcare/wp-content/uploads/sites/9/2019/06/Kickoff-Event-Presentation

1394. Implementation Guide: Toolkit for MRSA Prevention in ICU & Non-ICU Settings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/123-mrsa-toolkit-implementation-guide.docx
      October 01, 2024 - Evaluating & Sustaining Progress: Safety is not a one-time event that can be “solved.” … You can also draw on other valuable data, such as from your electronic health records and event reporting … associated with an increased duration of mechanical ventilation, and both VAP and NV-HAP are associated with adverse … Contaminated cultures lead to adverse consequences, including extended lengths of stay, inflated costs … a significant amount of antibiotics in hospital settings are prescribed inappropriately, leading to adverse

1395. Patient-Family-Centered-Care-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-transcript.doc
      April 09, 2013 - enough, a little before some of the easier places, is engaging with patients and families after an adverse … event. … to move toward transparency 15 years ago, getting the wisdom of individuals who had been involved in adverse … event. … Patients and families are equally involved in groups that are focused on how to communicate adverse events

1396. Patient and Family-Centered Care (April 9, 2013) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-transcript.html
      December 01, 2017 - enough, a little before some of the easier places, is engaging with patients and families after an adverse … event. … to move toward transparency 15 years ago, getting the wisdom of individuals who had been involved in adverse … event. … Patients and families are equally involved in groups that are focused on how to communicate adverse events

1397. Final Progress Report: The National Quality Forum National Annual Policy Conference 2006 (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/nishimi-report.pdf
      January 01, 2024 - relate to developing and testing interventions to reduce the risk of medication errors that lead to adverse … Serious Reportable Adverse Events in Healthcare Voting on the recommended revisions to this 2002 report … Serious Reportable Adverse Events in Healthcare Voting on the recommended revisions to this 2002 report

1398. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
      January 01, 2024 - substantially reduce medication error rates, studies have not been powered to detect differences in adverse … Patient experiences near death event. Process fails. Very high 1-3 per 10 events. … If the patient has an adverse drug reaction, the administration of the chemo is stopped, the reaction

1399. Medical Failure-to-Rescue Final Report (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/silber-report.pdf
      January 01, 2025 - been central to the formation of rapid response teams (RRTs) to detect and react to signs of adverse … Hospital and patient characteristics associated with death after surgery: A study of adverse occurrence … Adverse outcomes in patients with chronic liver disease undergoing colorectal surgery.

1400. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
      January 01, 2024 - healthcare (SHHC) after hospital discharge are among those at highest risk of re-hospitalization and adverse … the movement of a person from one healthcare setting to another and is frequently associated with adverse … identified numerous consequences resulting from IM-related process failures (e.g., delays in care, adverse