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Showing results for "adverse event".
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201. Peer Support Interaction—Physician: Video | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
     August 01, 2022 - This video demonstrates an example of emotional support provided for the physician caregiver after an adverse … event.

202. Peer Support Interaction—Nurse: Video | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/videos/nurses.html
     August 01, 2022 - This video demonstrates an example of emotional support provided for the nurse caregiver after an adverse … event.

203. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - To improve patient safety, it is critical to understand how clinical systems actually work and why adverse … NRE are defined as any event that is perceived to deviate from ideal care for that specific patient … of prospective studies but can be used stand-alone for active event surveillance. … The image on the left shows a desaturation (low oxygen) event after extubation. … drug event), and categorical elements.

204. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
     December 01, 2004 - An error may or may not result in an adverse event, which is an instance of a patient suffering the … Similarly, whether or not an error results in an adverse event may be related to patient characteristics … event. … If an error occurs in a process in the hospital, the adverse event is likely to occur in the hospital … that an individual may have for reporting an error or adverse event, and how that may affect the quality

205. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
     July 01, 2011 - more than 25 States have passed legislation or created regulations related to hospital reporting of adverse … Current Reporting Systems Current patient safety event reporting systems are aimed at obtaining information … view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse … Research to Create Patient Safety Event Reporting Systems for Consumers To develop recommendations for … • What is the most effective operational approach for consumers to report patient safety event information

206. Final Progress Report: Improving Patient Safety and Disease Management While on Contact Isolation (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/morgan-report.pdf
     January 01, 2024 - Results: We found no increase in adverse events related to patient isolation. … It is used to decrease the rates of the most common hospital adverse event, nosocomial infections … events while on contact isolation can be identified prior to the adverse event using a prediction rule … The effect of universal glove and gown use on adverse events in intensive care unit patients. … The effect of contact precautions on frequency of hospital adverse events.

207. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - These event types drive the collection of information germane to a specific event. … Adverse drug reaction (not a medication error) C. Equipment, supplies, and/or devices D. … Event type (modified UHC taxonomy) 37.6 Disposition of event 37.6 Procedure error: Procedure 30.0 … of the observed process error or adverse outcome devoid of analysis. … type, some of which (e.g., adverse drug reactions and complications) always presume harm. 11

208. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017.html
     November 01, 2017 - Drug Event Prevention. 4 Several efforts are underway at the Agency for Healthcare Research and Quality … Drug Event Prevention. 4 These documents articulate the goals, priorities, and measures for improving … Drug Events (ADE) An event in which administration of a medication results in harm to a patient. … Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/or … In the event that no substantial heterogeneity is observed from the random-effects model, we would then

209. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … understanding and correcting weaknesses in the health care delivery system and to preventing actual adverse … (as opposed to an adverse event or an error that had no potential for patient harm) and how to use the … event (AE, where the patient had suffered some harm). … Does error and adverse event reporting by physicians and nurses differ?

210. Appendix B. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appb.html
     August 01, 2022 - Developing the Improving Post-event Analysis and Communication Together (IMPACT) tool to involve patients … and families in post-event analysis. … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … Integrated approach to reduce perinatal adverse events: Standardized processes, teamwork training, and … Incidence of adverse events and negligence in hospitalized patients.

211. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - Drug Events Purpose: • To assess the impact of a web-based error/adverse event reporting system …  To assess the impact of stimulated reporting on reported error/adverse event rates. … event or potential adverse drug event was associated with the prescription. 5 Final Report: Improving … Although the pump did not reduce the serious error or adverse event rate, the findings of the study … event.

212. ChartBook On Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
     March 04, 2016 - event associated with hip joint replacement, adverse event associated with knee joint replacement, … event associated with hip joint replacement, adverse event associated with knee joint replacement, …  The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are … adult patients who received a hypoglycemic agent and had an adverse drug event  Percentage of … hospitalized adult patients who had an anticoagulant-related adverse drug event to warfarin  Number

213. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
     March 11, 2022 - Conference included sessions or posters on the following AHRQ-supported work: Common Formats for Event … Indian Health Service • Enhanced Adverse Event Reporting Capabilities: o Reporting of adverse events

214. 2024 Network of Patient Safety Databases Chartbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
     January 01, 2024 - has four Answer Values: Incorrect action; Unsafe condition; Adverse reaction; and Unknown. … The following are excluded from Medication or Other Substance event type reporting: ■ Adverse drug … decision to prescribe medication despite known drug-drug interaction) ■ Drug-drug, drug-food, or adverse … administering overdose or incorrect medication), Unsafe condition which excludes Incidents or Near Misses, Adverse … Among Medication or Other Substance event reports with complete event descriptions, the majority

215. Measure Descriptions for Daily Early Mobility: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-slides.html
     February 01, 2017 - Adverse events. Event types. … Event codes are listed on the back of the data collection sheet. … Slide 30: Event Codes Image: Event codes for recording events that occur during mobilization. … Adverse event incidence rate (intubated and non-intubated). … Top 10 adverse events for ventilated and nonventilated patients.

216. VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
     September 26, 2023 - complex, high-risk environments Fewer than anticipated accidents or events of harm An “accident or event … of harm” could be more broadly defined as any event that causes disruption to safe and reliable operations … across the system Unclear Policy Error in Data Report Unjust Response to Adverse Event Operating … /AE reporting ratio may indicate a positive reporting culture in which Close Calls are reported and Adverse … Leadership Engagement Stop the Line Close Call (CC)/Adverse Event (AE) Reporting These documents

217. Just Culture Webcast Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
     May 01, 2007 - Education • Two Nurse Managers • Pediatrician • Anesthesiologist The Collaborative • Prework – RCA Event … Action Reports – Patient Safety Activity Documentation – Policies; Corrective Action, Sentinel Events, Adverse … Event Reporting – Patient Safety Plan – Code of Conduct, Employee Handbook, Medical Staff Bylaws • … When a patient safety event happens, hospital management looks at more than staff actions to determine … what led to the event.

218. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/eval4.html
     May 01, 2016 - conducted, what contributing factors were identified, whether a matching report was found in the staff adverse … For comparison, spontaneous reporting from hospital-based adverse event reporting systems for health … n The term “negative effect” tested well in focus groups and cognitive testing, in contrast to “adverse … The system distinguishes between adverse events that are preventable, adverse events that are not preventable … q An “adverse event” in the IOM classification system is equivalent to an “incident” in the AHRQ Common

219. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - Data collected for incidents included description of the event, classification of the event, where the … event occurred, services and personnel involved, and additional work resulting from the event. … the event, where the event occurred, services and personnel involved, and additional work resulting … from the event. … Morbidity and disability data were collected until discharge for all patients with an adverse event,

220. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
     January 01, 2002 - event reports involving medical devices, including infusion pumps. … A fourth phase reviewed the MAUDE database for all adverse event reports related to the infusion pumps … Interface Design for Infusion Devices 329 Relationship between studies of devices and adverse event … Attempts have been made to create adverse event reporting systems to capture and analyze incidents … Adverse event reports suggest that human–computer interactions are the “root cause” of the majority