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Showing results for "adverse event".
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdfJune 11, 2003 - We needed a new, improved system of reporting occurrences—actual adverse events or near misses that … Occurrence screen reporting flow diagram Adverse Event or Near Miss Identified Verbal report or form … given to Patient Safety Specialist Event is inputted into database Staff willl enter event into system … If an adverse event does reach a patient, the occurrence or medication error may require a formal review … A total of 8 percent felt that only a slight chance of adverse actions would be possible.
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www.ahrq.gov/npsd/data/chartbook/index.htmlFebruary 01, 2025 - provide an overview of the patient safety data captured in the NPSD through the AHRQ Common Formats for Event … They examine data for topics that cut across the multiple modules in the AHRQ Common Formats for Event … Reporting for Hospitals ( CFER-H, versions 1.1 and 1.2 ), including generic safety concerns and adverse
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Staff-Safety-Assessment (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/staff-safety-assessment.docxJune 01, 2021 - Safety Assessment PURPOSE OF THIS FORM: To discuss issues that may result in antibiotic-associated adverse … events or have the potential to cause adverse events that could negatively impact patient safety. … Category Unit Please describe how you think the next resident at your facility will be harmed by an event -
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdfNovember 01, 2021 - • Patient safety concerns such as falls, pressure injuries, and adverse medication events were reported … event, etc.). … Among the blood and blood product concerns (n = 10; 3.3%), there were three incidents involving an adverse … In two instances, adverse reactions to medications used to treat COVID-19 were identified. … intervention in place o Secondary patient morbidity • Surgery or anesthesia o Characteristics of surgical adverse
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Facilitator-Notes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docxMarch 01, 2017 - SLIDE 27 SAY: Communication following an adverse event can been especially challenging. … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … , the resident’s response to the event, and the care provided as a result of the event. … important to remember that residents and family members can experience a number of emotions when an adverse … event occurs, so communication about an adverse event should be compassionate and sensitive. -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdfJanuary 01, 2004 - financially distressed hospitals are 13.7 percent more likely to have a surgery-related patient safety event … These five adverse events are indicated with an asterisk in Table 5. … patient safety event at hospital h, during year t. … , year-fixed effects, δ t, are included to control for statewide changes in average patient safety event … The probability of a patient safety event at hospitals with margins ranging from 0 percent to 5 percent
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Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdfJanuary 01, 2024 - event rates. … event rate was normalized according to the number of events per person-year. … Additionally, to assess adverse event frequency, we relied on systematic error surveillance that was … Sentinel event statistics released for 2014. The Joint Commission Online. … Sentinel event statistics data: root causes by event type. 2014. -
www.ahrq.gov/patient-safety/reports/advances/index.htmlJuly 01, 2022 - Event Hospitalizations ( PDF , 194 KB) Robert R. … Hilborne, Quang-Tuyen Nguyen What Happens After a Patient Safety Event? … Glasgow Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting ( … Hickner, Deborah Graham, Michele Johnson Lessons Learned from the Evolution of Mandatory Adverse Event … Hilborne Standardizing Medication Error Event Reporting in the U.S.
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www.ahrq.gov/patient-safety/reports/hotline/implement3.htmlMay 01, 2016 - development of protocols for processing patient and caregiver reports and for identifying any matching adverse … event reports made by staff within the organization. … Both organizations have a history of hospital-based adverse event and complaint reporting systems that … Both encourage adverse event reporting by staff and have internal mechanisms for staff to report incidents … Terms like “safety” and “error” may suggest that the hotline is interested only in serious adverse events
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www.ahrq.gov/patient-safety/resources/learning-lab/owll-long-desc.htmlAugust 01, 2025 - aimed to improve patient safety in dental settings by establishing a learning health system that used adverse … event (AE) data to identify safety risks and test targeted interventions. … Identifying contributing factors associated with dental adverse events through a pragmatic electronic … An observational retrospective study of adverse events and behavioral outcomes during pediatric dental … Identifying contributing factors associated with dental adverse events through a pragmatic electronic
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdfJanuary 01, 2019 - Measures used to estimate the national HAC rate HAC Type Source Measure Adverse Drug Event MPSMS … Event Associated With Hip Joint Replacements MPSMS Adverse Event Associated With Knee Joint Replacements … event. … are used, we follow these steps: • Multiply the adverse event rate for each of the 21 HACs for patients … MPSMS Adverse Event Associated With 41,639 1.40 40,500 1.36 42,398 1.43 48,518 1.63 Knee Joint
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdfJuly 01, 2023 - event or mitigated its harm.5,12 Although patient accounts do not always convey a complete picture … event or mediated its impact.16,26,36 iWe will henceforth use the term “family” as a shorthand for … event.43 But these studies are largely limited to treatment-related errors. … Trends in adverse event rates in hospitalized patients, 2010-2019. … Families as partners in hospital error and adverse event surveillance JAMA Pediatr. 2017;171(4):372-
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www.ahrq.gov/sites/default/files/2025-02/umoren-report.pdfJanuary 01, 2025 - A systemic review on neonatal transport risks and adverse safety event reporting was conducted (29). … Neonatal transport discrete event simulation model: The neonatal transport model is based on discrete-event … Human factors are the root cause of 67% of avoidable adverse events on transport, with most adverse … Neonatal Transport Safety Metrics and Adverse Event Reporting: A Systematic Review. … Neonatal Transport Safety Metrics and Adverse Event Reporting: A Systematic Review.
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www.ahrq.gov/sites/default/files/wysiwyg/topics/diagnostic-safety-workgroupmeeting-notes-july2022.pdf.pdfNovember 03, 2022 - • Common Format for Event Reporting – Diagnostic Safety o AHRQ released the Common Formats for Event … The Event Description, Users’ Guide and Glossary, and Form are all available here. … IHS • Enhanced Adverse Event Reporting Capabilities o IHS Safety Tracking and Response (I-STAR) is deployed … improvement project to better identify and facilitate the reporting of diagnostic errors through voluntary event
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.htmlAugust 01, 2022 - to establish an initiative to help States and health care systems test new models of care delivery, adverse … event disclosure, and dispute resolution, with the joint aims of (1) putting patient safety first by … communication interventions; (2) improving patient safety by measuring safety problems, characterizing adverse … previously collected patient complaint data suggests that patient complaints may be a predictor of adverse … occurred across all types of medications and in 41% of cases sampled in this study may have caused adverse
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/resident-covid-vaccine-administration-record.docxMay 01, 2022 - Contraindication:__________________________________________________________________________ Adverse … Event (Reaction) to Current Vaccine Administration – Describe any reaction to vaccine: _________ … ______________________________ Refer to the CDC’s website for information on contraindications and adverse
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Staff COVID-19 Vaccine Administration Record (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/staff-covid-vaccine-administration-record.docxMay 01, 2022 - Contraindication: __________________________________________________________________________ Adverse … Event (Reaction) to Current Vaccine Administration - Describe any reaction to vaccine: _________ … _____________________________ Refer to the CDC’s website for information on contraindications and adverse -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdfMay 28, 2008 - A medication error causing injury to the patient (preventable adverse drug event). 2. … drug event or a serious medication error without injury, severity of the error is also rated. … For classification of an event as a preventable adverse drug event, serious error without injury, or … Medication errors and adverse drug events in pediatric inpatients. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention.
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www.ahrq.gov/nursing-home/resources/search.html?page=13January 01, 2022 - Vaccine Adverse Event Reporting System Reporting Form This webpage hosts a writable PDF form that provides … instructions for reporting a vaccine adverse event.
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What Exactly Is Patient Safety? (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdfJuly 02, 2008 - In short, the analytic method must be unique to the adverse event, but then the safety sciences use … The analysis of what went wrong when an adverse event has occurred is known as “root cause analysis” … event. … Often an adverse event that is about to unfold can be averted or its impact minimized if it is caught … So, when designing a system, improving a system, analyzing an adverse event, researching an issue, or
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