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Showing results for "adverse event".
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301. Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Harney_89.pdf
     May 01, 2007 - Adverse events identified during the pilot study included: hemangioma, oropharyngeal bleed, bleeding … Additional information was gathered (e.g., unit, service, education needed, adverse event), coded, and … On review of data obtained from the CHB Safety Events Reporting System, adverse event rates in FY 2005 … There is no available literature describing the rate of readmissions for pediatric patients with an adverse … event due to anticoagulation therapy.

302. Connecticut Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201806.html
     October 01, 2018 - Connecticut Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools Search All Impact … questionnaire were part of a comprehensive patient safety program launched in 2013 for measuring preventable adverse … We’ve found that preventable adverse events resulting in moderate to severe harm or death have dropped

303. Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
     April 14, 2008 - drug event reporting systems (e.g., VHA Patient Safety Reporting System)15 or mandatory State serious … drug reactions.26 This project primarily uses clinical event reports from investigators and other clinicians … drug event reporting and medication safety administrative programs.27 The VHA health service’s … This is especially important when the outcome of interest is a very rare event. … Maximizing the use of State adverse event data to improve patient safety.

304. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
     January 01, 2024 - Project 1: Innovative Statistical Methods for Large-Scale Drug/Adverse Event Screening Purpose and Scope … event B. … In addition, a specific adverse event over a specific time window for a particular drug of interest … The methodology is applicable to any adverse event (e.g., myocardial infarction) or combination of events … event rates.

305. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - First, the top-level event is not an “adverse drug event” in the sense that it has resulted in harm; … Risk factors for adverse drug events among nursing home residents. … Epidemiology of adverse drug events in the nursing home setting. … Relationship between medication errors and adverse drug events. … Systems analysis of adverse drug events.

306. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
     November 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention provides a strategy for preventing adverse … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

307. Followup to the PSML Demonstration Projects | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/followup.html
     August 01, 2022 - and UW), each hospital can customize the toolkit based on its needs in several core areas, including: adverse … event reporting, process improvement, communication and disclosure, care for the caregiver, and resolution

308. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - clinician attitudes about the disclosure of individual, team, and system failures associated with four adverse … members tended to agree on which system failures were important to disclose, regardless of the type of adverse … Clinician responses were more varied and were affected by type of adverse event, but they did agree with … drug event (ADE), the severity of the ADE (i.e., serious, significant, minor), the potential health … Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event

309. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
     March 01, 2012 - The risk for such adverse events increases when surgery is performed in an environment that is less … 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 … 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

310. Making Healthcare Safer III | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html
     August 01, 2024 - Harms such as adverse drug events, healthcare-associated infections (HAIs), falls, and obstetric adverse … 415.4 KB) Harms Due to Anticoagulants (PDF, 2 MB) Harms Due to Diabetic Agents (PDF, 1.6 MB) Reducing Adverse

311. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Scope and Significance Preventable Adverse Drug Events in Community Pharmacies Adverse drug events (ADEs … drug event (PADE),7 which is a harmful medication error. … Direct comparisons using these studies were limited by differences in event definitions, event categories … Review of the Food and Drug Administration handling of adverse drug event reports. … FDA MedWatch: The FDA Safety Information and Adverse Event Reporting Program Web site. www.fda.gov/medwatch

312. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
     June 02, 2025 - 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.

313. Identifying Barriers to the Success of a Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
     March 01, 2004 - physicians are reluctant to participate in programs to report medical errors, and that underreporting of adverse … Underreporting rates of adverse events identified following implementation of a reporting system * … Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999;5:13–21. … Reasons for not reporting adverse incidents: an empirical study. … Underreporting rates of adverse events identified following implementation of Figure 2.

314. Final Progress Report: NYU Patient Imaging, Quality and Safety Laboratory (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/horwitz-report.pdf
     January 01, 2025 - event reviews, and root cause analyses. … event reporting system, interviews and focus groups, and surveys of staff and patients. … event reports Results This grant has generated numerous problem analyses and subsequent interventions … We have conducted dozens of qualitative interviews, reviewed hundreds of adverse event reports, spent … Assessment of adverse events associated with peri-procedural handoffs We reviewed 375 adverse event

315. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pptx
     January 01, 2006 - The QIs are a set of indicators for adverse events that patients may experience as a result of an inpatient … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … You may also want to report the number of patients with the adverse event to make it more tangible to

316. 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/hospitalresourcelist.pdf
     January 01, 2019 - • 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. … of event reporting, and how event reports can be used to improve safety. … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systemic issues contributed to the event.

317. Info FAQs | Agency for Healthcare Research and Quality
     www.ahrq.gov/faqs/index.html?page=4
     June 12, 2025 - through retrospective review of medical records, information that is complementary to that derived from event … These Formats will facilitate improved detection of events and calculation of adverse event rates in … Previously, Common Formats have been designed to support only traditional event reporting. … Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events … Three HSOPS dimensions were dropped from the nursing home survey: Frequency of event reporting, Teamwork

318. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
     January 01, 2024 - event outcomes has made it more difficult to identify cost-effective approaches for improving patient … We also collected data on state laws and policies related to patient safety and event reporting. … event reporting laws and PSIs. … Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. … Use of morning report to enhance adverse event detection.

319. Tool: Call-Out | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
     May 01, 2023 - Or a patient having wisdom teeth removed may have a strong adverse reaction to the sedation and require … Afterwards, consider how the use of call-outs helped the team during an emergent event:  How did … the call-outs made by the nurse and intern aid the team during this emergent labor and delivery event

320. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - diagnostic errors were a chief concern in outpatient visits 1 in 9 ED admissions are related to an adverse … drug event An estimated 160 million medication errors occur each year in primary care