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Showing results for "adverse event".
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261. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - Study of Adverse Events (ENEAS). … The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. … Incidence and types of adverse events and negligent care in Utah and Colorado. … Adverse events in British hospitals: preliminary retrospective record review. … What can hospitalized patients tell us about adverse events?

262. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
     April 01, 2018 - It utilizes both quantitative and qualitative data to "map" the risks associated with adverse outcomes … interact with one another and either individually or collectively combine to contribute to the overall adverse … Is proactive, identifying the possible adverse events before they actually occur, thus enabling the decision … modeling of complex interactions and dependencies among the multiple risk points that may lead to the adverse … this approach is determining the probabilities associated with human breakdowns that contribute to adverse

263. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
     January 01, 2004 - drug event (ADE) ranges between $2,300 and $4,685.5, 6 As greater attention is given to medication … The risk manager begins the medication error report investigation by sending details of the event to … Policy and the future of adverse event detection using information technology. … Developing a comprehensive electronic adverse event reporting system in an academic health center. … Using administrative data to improve compliance with mandatory state event reporting.

264. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
     January 01, 2024 - Scope: The National Action Plan for Adverse Drug Event (ADE) Prevention identified three high-priority … Drug Event Prevention: Targeting High-Risk Drug Classes: The National Action Plan for Adverse Drug … Step 2 – Event Identification: An event summary was prepared whenever the clinical pharmacist identified … The event summary also captured information to assess the probability of an adverse event being attributable … National Action Plan for Adverse Drug Event Prevention. 2014; http://www.health.gov/hai/pdfs/ADE-Action-Plan

265. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - They may not be obvious until a triggering event occurs. … This patient had a recent cardiac event, which can lead to lower extremity swelling. … Sometimes we forget to acknowledge the factors that reduce potential harm from the adverse event. … This can come from a near-miss or sentinel event, as in the case described in this presentation. … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.

266. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
     April 06, 2008 - • Was this a one-time event or a point on a trend line? … • Was this a one-time event or a point on a trend line? … In this incident causation model, near misses are precursors to possible adverse events. … The attributes of medical event reporting systems: Experience with a prototype medical event reporting … misses and adverse events.

267. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
     September 10, 2015 - Reporting, Event Investigation and Analysis Module 4 of the CANDOR Toolkit covers the Event Reporting … information on the event. … in event reporting, including; How the event was reported. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.

268. Staff Presentation Template (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pdf
     July 01, 2004 - • The AHRQ QIs are a set of indicators for adverse events that patients may experience as a result of … – Consider inserting here the deidentified story of a patient who suffered the adverse event captured … You may also want to report the number of patients with the adverse event to make it more tangible to … – Consider inserting here the deidentified story of a patient who suffered the adverse event captured

269. Hospital Survey Version 2.0: Background and Information for Translators | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/international/hospital/translators-version-2.html
     October 01, 2024 - When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports. … Hospital management seems interested in patient safety only after an adverse event happens. … item: Hospital managers are only interested in doing something about patient safety when there is an adverse … event or a patient is harmed. 10.

270. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
     June 01, 2023 - Trends in adverse event rates in hospitalized patients, 2010-2019. … The missing evidence: a systematic review of patients’ experiences of adverse events in health care. … Families as partners in hospital error and adverse event surveillance. … Can we rely on patients’ reports of adverse events? Med Care  2011;49(10):948-955. … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review

271. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors and adverse … events • Facilitating a more rapid response after an adverse event has occurred • Tracking and providing … feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors and AEs

272. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
     December 01, 2024 - of event reporting, and ways event reports can be used to improve safety. … • Implement a Care for the Caregiver program for providers involved in adverse events. … • Investigate and analyze an adverse event to learn from it and prevent future adverse events. … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … Patient Safety Primer: Medication Errors and Adverse Drug Events 21.

273. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - An event that causes harm is typically called an adverse event (e.g., retained surgical instrument); … at risk of the event). … Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical … Reporting of adverse events. N Engl J Med 2002; 347: 1633-1638. 6. … Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051-1056. 19.

274. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - An error was defined as “any event in a patient’s medical care that did not go as intended and either … The reports were reporter- anonymous and included a description of the event, identification of the patient … , job classification of the reporter, and suggestions for prevention of such an event in the future. … The team reviewed each reported event to identify contributing factors and seek root causes. … Will, ideas, and execution: Their role in reducing adverse medication events.

275. Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Masheter.pdf
     March 01, 2004 - Adverse event classes of ICD-9-CM codes AHRQ-funded patient safety reporting demonstration projects … Utah/Missouri adverse event ICD-9-CM classification. 2002 Version 1. … Comparison of AHRQ Patient Safety Indicators and Utah/Missouri Adverse Event Classes Table 2. … Comparison of AHRQ Patient Safety Indicators and Utah/Missouri Adverse Event Classes for complications … Number and percentage of inpatient discharges with any adverse event class by adverse event type and

276. Information to Help Hospitals Get Started
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pptx
     July 23, 2010 - patient-centeredness of care have seen subsequent improvements in patients’ ratings of care.4 References: Sentinel event … decrease in time for shift report.4   [Include hospital specific goals or data] References Sentinel event … Nearly 20% of patients experience an adverse event within a month of discharge, of which ¾ could be prevented … Nearly 20 percent of patients experience an adverse event within 30 days of discharge.1,2 Research shows … The incidence and severity of adverse events affecting patients after discharge from the hospital.

277. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - can redesign care and delivery processes to improve care and minimize the occurrence of errors and adverse … checklists, and create independent checks for key processes, we improve our ability to reduce the risks of adverse … Adverse event reporting systems are common in hospitals. … Slide 17: Staff Safety Assessment Say: Adverse reporting systems, sentinel events, and claims data … are reactive—the unfortunate event has already occurred.

278. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - event). … Sentinel Event Alert, Issue 6. … Sentinel Event Alert, Issue 24. … Sentinel event trends: Wrong-site surgeries reported by year. … event reporting systems.

279. Monthly Team Checkup Tool for MRSA Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/118-monthly-team-checkup-tool.pdf
     October 01, 2024 - rounding stating specific goals for the patient that day (e.g., Daily Goals)  Learning from defects or adverse … In the past month, has a disruptive event distracted unit personnel from the MRSA Prevention work (e.g … ., emergency response, reorganization, sentinel event, accreditation activities, loss of key personnel … , sentinel event, accreditation activities, loss of key personnel)? … “THE CUSP TEAM DID NOT MEET” IS SELECTED, SKIP TO QUESTION 10: ]: Off Learning from defects or adverse

280. Strategy 4: IDEA Discharge Planning (Tool 3) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
     January 01, 2010 - engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … event within 30 days of discharge.1,2 Research shows that three-quarters of these could have been … prevented or ameliorated.1 Common post-discharge complications include adverse drug events, hospital-acquired … The incidence and severity of adverse events affecting patients after discharge from the hospital.