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1461. Postdischarge Followup Phone Call Script (Patient Version) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdisphone.pdf
      June 02, 2025 - Medicines High Alert Medicines Use the guide below to help monitor medicines with significant risk for adverse

1462. Mutual Support: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - feedback during debriefs or individual‐level feedback during one‐on‐one interactions • Post‐case or event … a great tool to help reinforce and establish a culture of huddles for high‐risk patients and post‐event … Use DESC to provide feedback during debriefs or in one‐on‐one interactions between providers post‐event … lead to stroke or seizures she needs to know what treatment options are available to prevent such adverse

1463. Mutual Support: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
      July 01, 2023 - feedback during debriefs or individual-level feedback during one-on-one interactions Post-case or event … is a great tool to help reinforce and establish a culture of huddles for high-risk patients and post-event … Use DESC to provide feedback during debriefs or in one-on-one interactions between providers post-event … can lead to stroke or seizures she needs to know what treatment options are available to prevent such adverse

1464. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
      January 01, 2005 - Systems analysis of adverse drug events. ADE Prevention Study Group. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

1465. Scoring CPCQ (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cpcq-scoring.pdf
      May 01, 2017 - Conclusions: Multiple imputation is a clear leader in accuracy for dealing with missing data, though even in adverse … Notable Findings: Three methods remain reasonably accurate in the event that response is related to

1466. Final Progress Report: Comprehensive Analysis of Data from Testing the Re-engineered Hospital Discharge (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/chetty-report.pdf
      January 01, 2024 - As one may suspect, various factors contribute to a rehospitalization or an adverse event.

1467. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
      September 01, 2013 - Safety and Adverse Events 3 Introduction and Welcome This enhanced protocol is … from the manufacturer show that less than 1 percent of patients in clinical trials withdrew due to adverse … To avoid having persistent bacteremia count as multiple events, allow only one event per patient. … In the event the patient is incontinent and being sent to radiology, communicate that the patient is … Product Safety and Adverse Events Chlorhexidine (CHG) Risk The risks associated with the use

1468. Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/unruh-report.pdf
      January 01, 2025 - Composite PSI composite of complications Weighted average of reliability and risk-adjusted rates of adverse … PSI indicators were rates of adverse events, such as pressure ulcers, postoperative respiratory failure … Licensed nurse staffing and adverse events in hospitals. Med Care 2003 41(1): 142-152.

1469. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
      June 03, 2021 - Infrastructure (e.g., electronic medical records, event reporting systems) 3. … Learning from malpractice claims about negligent, adverse events in primary care in the United States

1470. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
      June 03, 2021 - Infrastructure (e.g., electronic medical records, event reporting systems) 3. … Learning from malpractice claims about negligent, adverse events in primary care in the United States

1471. A Clinical Assessment Program to Evaluate the Safety of Patient Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Snow.pdf
      January 01, 2010 - perioperative beta-blockade to patients at risk for cardiac events, thus increasing the patient’s risk of an adverse … event and reducing the safety of their care. … Adverse events and their association with treatment regimens in the Diabetes Control and Complications

1472. Creating a Curriculum for Training Health Profession Faculty Leaders (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
      March 31, 2004 - from multiple professions together to search for the multiple contributory factors at the root of an adverse … cultures recognize that there is much to be gained by negotiating rather than discounting differences in event … in patient safety concepts as well as in fostering cultural changes leading to open discussion of adverse

1473. 003-Ss-Antimicrobial-Prophylaxis-Part-2-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/003-ss-antimicrobial-prophylaxis-part-2-fg.docx
      April 01, 2025 - Doing so minimizes adverse side effects of the medication, minimizes the development of resistance, and … This practice increases the risk for several adverse outcomes, without doing anything to reduce SSIs. … retrospective cohort study within the Veterans Affairs (VA) system examined types of prophylaxis and adverse … To prevent these adverse effects, document a thorough allergy history, and engage in pre op allergy testing

1474. Improving Patient Safety in Long-Term Care Facilities, Module 3 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
      June 01, 2012 - When things go wrong (adverse events) or look as if they are about to (near-misses), we may feel embarrassed … – residents and staff – does better when people support discussion and learn from near misses and adverse … Nursing assistants and licensed nurses must cooperate to observe and evaluate the specific fall event

1475. Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/mincer.html
      August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … and who takes greater ownership of the shared decision, would be less likely to file a lawsuit in the event

1476. Final Progress Report: Developing and Disseminating a Patient Safety Risk Assessment (PSRA) Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/joseph2-report.pdf
      January 01, 2024 - with other factors (e.g., organizational culture, operation) in complex ways, impacting the risk of adverse … It will be a significant step forward in enhancing patient and staff safety through reducing adverse … tool dissemination, because the annual conference has been a major healthcare design and construction event … Safety First: Designing Healthcare Spaces To Avoid Adverse Events. Healthcare Design Magazine. … Safety by Design: How Teams Can Proactively Use Facility Design to Reduce Adverse Events.

1477. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
      January 01, 2006 - Six Sigma reduced the risk score in moderate sedation from 11.94 to 4.94 and event probability score … Six Sigma initiatives in these areas have resulted in a 44 percent reduction in adverse drug events, … pediatric moderate sedation decreased the mean risk score from 11.94 to 4.94 (16-point scale) and the event

1478. Metabolic Monitoring for Children and Adolescents on Antipsychotics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-fullreport.pdf
      February 14, 2018 - of psychiatric disorders in children, these medications are associated with a number of potentially adverse … Fiscal Burden Although there is little research available on the fiscal burden associated with adverse … aspect of proper medication management in this population, as these medications are associated with adverse … Antipsychotics are associated with potentially adverse metabolic impacts that include weight gain, diabetes … Health-care costs of pediatric clients developing adverse events during treatment with antipsychotics

1479. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
      January 01, 2024 - on our focus group findings regarding the potential contribution of a hectic office environment to adverse … One finding, the potential contribution of a hectic office environment to adverse patient outcomes, … We encourage the internal reporting of all adverse patient care events. 2.5 (0.9) z. … The chaotic office environment plays a prominent role in explaining adverse physician reactions including … remediable contributors to a chaotic environment, 2) the relationship between the chaotic environment and adverse

1480. 012-Blood-Culture-Practices-Webinar (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/012-blood-culture-practices-webinar.docx
      October 01, 2024 - False positives caused by contamination result in further adverse consequences, including unnecessary … algorithm differentiates between initial indications for blood cultures in the setting of a new clinical event … For a new clinical event, the first question is whether severe sepsis/septic shock or endovascular infection