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Showing results for "adverse event".
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321. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
     January 01, 2024 - evaluation of error-prone healthcare processes may inform interventions to prevent adverse patient … event. … Most errors and adverse events in this transition involve communication breakdowns in handoffs between … event. … probability scores, the team recognized that simultaneously scoring the severity and the probability of an event

322. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
     January 01, 2024 - A medication error is a preventable event that occurs in the process of ordering, processing, or administering … This information can supplement traditional methods of event detection, such as clinician self-report … Medication event detection. … voluntary reporting by nurse and physician subjects was augmented by deployment of the handheld Medication Event … web-based reporting tool that captured detailed information regarding the specific attributes of the event

323. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - Active failures occur when an “operator” performs an unsafe action that leads to an event. … In an active failure, their action directly contributes to the event. … In other words, active failures are the adverse events the team thinks about and attempts to avoid. … The result is an adverse event or patient error, which can result in catastrophic outcomes such as permanent … In most cases, the event would have eventually happened regardless of who the provider was.

324. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
     June 01, 2014 - The annual estimates include a wide variety of adverse events, including the nine HACs selected for … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Adverse … Drug Event (ADE) MPSMS ADE Associated With Digoxin 9,400 0.29 11,000 0.32 MPSMS ADE Associated … 1,000 Discharge s Falls MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse … Events Associated With Hip Joint Replacements 33,000 1.00 31,000 0.93 MPSMS Adverse Events Associated

325. Statin Therapy Measure Narative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cholesterol-narrative.pdf
     December 31, 2018 - Registered Nurses (APRN) Ages 21 years and older as of January 1 of the measurement period Event … Patients who met any of the following criteria are identified as at high risk of a cardiovascular event … Denominator Exceptions • Patients with adverse effect, allergy or intolerance to statin medication … Measure Type Process Description Methodology Eligible Population Eligible Providers Ages Event

326. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - Adverse event/error types among published cases* Delayed or missed diagnosis 15 (27%) Adverse … numbers don’t add up to 55, because each of the 55 cases could have more than one type of error or adverse … event. … Sentinel Event Alert. Joint Commission on Accreditation of Healthcare Organizations. … Adverse event/error types among published cases* Figure 1.

327. Improving Communication and Teamwork in the Surgical Environment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-slide-set.pptx
     May 01, 2017 - PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events). … Next Steps Report to appropriate parties Communicate with the patient and/or family Document event … PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events).

328. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - communication differences, will also need to be addressed to make the most of such efforts. 59,61,62 Real-time adverse … event and “near-miss” reporting systems, akin to those intended for use by clinicians, are another potential … records is through the “trigger” approach, which aims to “alert patient safety personnel to possible adverse … events so they can review the medical record to determine if an actual or potential adverse event has … research has examined the predictive validity of NLP algorithms for detection of safety incidents and adverse

329. The End of the Public Health Emergency Refocuses the Urgency to Improve Healthcare Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
     May 01, 2023 - England Journal of Medicine that estimated 1 in 4 people hospitalized are at risk of a patient safety event … Trends in adverse event rates in hospitalized patients. JAMA  2022 Jul 12;328(2):173-83.

330. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - Between 19 to 28 percent of patients experience adverse events during care transitions. … These adverse events, which may lead to hospital readmissions, represent an ongoing threat to patient … associate professor of medicine at Harvard Medical School in Boston, Massachusetts, is helping to reduce adverse … Building on his efforts to reduce adverse events during care transitions, Dr. … undergone at other facilities, enabling continuous and quality care and reducing the potential for adverse

331. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/waever.html
     August 01, 2017 - evaluating interventions targeting liability-related issues, such as disclosure, transparency, and event … event influence the probability that a claim is pursued, whether it is deemed meritorious, and the type … event. 23 , 26 Thus, while the patient safety improvement literature underscores the importance of … Paid malpractice claims for adverse events in inpatient and outpatient settings. … Exploring relationships between hospital patient safety culture and adverse events.

332. AHRQ Report to Congress Describes Sepsis’ Burgeoning Burden on Hospital Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/929.html
     September 01, 2024 - Reducing Patient Safety Events A new analysis of hospitalized Medicare patients reveals a decline in adverse … events since the peak of the COVID-19 pandemic, with a 13-to-15 percent reduction in adverse events … The report, Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (PDF, 2 MB), was led … Safety Review System (QSRS) , a new one-of-a-kind national repository that includes data on 41 types of adverse … Among report highlights: in 2022, 6.2 percent of Medicare patients experienced at least one adverse event

333. Antibiotic Stewardship Program (ASP) Development
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-slides.pptx
     June 01, 2021 - antibiotics only when necessary, thereby protecting residents from unnecessary antibiotic exposure and adverse … Developing a Program 9 10 Identifying the Problems—2 Clinical Event Son notes resident has dark … Developing a Program 11 12 Identifying the Problems—4 Clinical Event Son notes resident has … Developing a Program 12 Clinical Event Son notes resident has dark urine, with a foul odor. … Cost of antibiotics Use of guideline-concordant antibiotics Clostridioides difficile infection rates Adverse

334. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c3_pdi_staffpresentation.pptx
     January 01, 2006 - pdi_resources.aspx The PDIs are a set of 16 indicators that reflect quality of care inside hospitals and adverse … 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

335. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … event will occur in the range of 3 to 4 per every 1,000 admissions.4 When the management and medical … their infections.22 Moreover, operative and postoperative complications were the number-two sentinel event … Sentinel event statistics. … Sentinel Event Alert, 28: 2003. http://www.jcaho .org/about+us/news+letters/sentinel+event+alert/print

336. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201411.html
     August 01, 2014 - In recent years, the survey findings have helped Mercy Health revamp its patient safety event reporting … system, develop event management guidelines, and decrease reportable events. … safety and quality activities at Mercy Health, including the following: Implementing SAFECARE, an event … reporting system that dramatically reduced the amount of time required to enter an event or near-miss … Implementing "Just Culture Principles," which include creating an open and just environment, learning from adverse

337. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
     March 01, 2004 - Logistic regression was used to model the risk of an adverse event in the next quarter. … event. … and adverse event did not occur); and (3) “unexpected” or potentially avoidable adverse outcomes (i.e … ., resident was “low risk” based on comprehensive risk model, but adverse event occurred). … • Support responses to survey team (e.g., help demonstrate that adverse event was unavoidable).

338. Final Progress Report: Interactive HIT to promote ambulatory safety among vulnerable diabetes patients (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/sarkar-report.pdf
     January 01, 2024 - PURPOSE The objective of this study was to characterize adverse events and potential adverse events … We hypothesized that diabetes patients will experience adverse events and potential adverse events, … events were situations that could lead to an adverse event occurring (e.g., not having a functioning … with the automated telephone system would have an increased opportunity to trigger a potential safety event … Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

339. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=5
     January 01, 2024 - Adults Publication Date: June 2019 Developing Evidence for Safety Surveillance from Device Adverse … Event Reports ( application/pdf 811703 ) Principal Investigators: Mao, Sedrakyan, and Johnson Grant … Review Process of High-Risk Drugs Using a Patient-Centered, Telemedicine-Based Approach to Prevent Adverse … 023464 Topic(s): Medication Safety, Nursing Homes Publication Date: September 2018 Reducing Adverse

340. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - necessary to prospectively analyze or concurrently compare causal mechanisms for different types of adverse … an undeveloped event. … Each medication adverse event investigated by State agencies or participating facility will become a … Incidence and preventability of adverse drug events in nursing homes. … Systems analysis of adverse drug events. JAMA 1995;274:35–43. 20.