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Showing results for "adverse event".
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401. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
     January 01, 2025 - Scope: TI is a life-saving procedure; however, it is often associated with adverse outcomes in PICUs … Our preliminary single-PICU data documented adverse TI-associated events (TIAEs) occur among >20%. … Discussion: Adverse TI events were common across diverse pediatric ICUs. … We currently are evaluating the impact of this project with targeted outcomes: adverse TIAEs. … Association of vagolytic and ketamine use with tracheal associated adverse events.

402. Innovative Use of Technology in Primary Care Delivery - Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/innovative-use-pcr-091423.pdf
     September 14, 2023 - MAS (University of California, San Francisco, School of Medicine), ExPERTS-PC: Engaging Patients in Event … & Community Medicine, University of California, San Francisco 10 Background • Ambulatory adverse … diagnostic error annually ► 4.5 million ambulatory care visits annually in US may have been related to an adverse … drug event … liquid concentration ► Narrow therapeutic windows ► Drug-drug interactions • 5x higher odds of an adverse

403. Early Mobility in the Intensive Care Unit: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-fac-guide.html
     February 01, 2017 - Slide 11: Safety Say: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 14: Adverse Events Say: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The event rates ranged from 2.3 to 8.7 per 100 patients.

404. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
     June 18, 2008 - drug event. … the literature.9 Defined by traditional “threshold criteria” (at least one 2 minute or longer low-RR event … Defined conservatively (at least one ≥3-minute low-RR event, RR <10 bpm), the incidence of RD was 41 … Misprogramming IV infusion pumps can result in serious, potentially life threatening adverse events.20 … drug event.2 While some patient populations are at higher risk of an opioid-related event, clinical

405. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - enrich clinicians’ understanding of patient and family experience and reduce the harms that follow adverse … Although patient and family conceptions of adverse events do not always conform to clinical definitions … diagnostic errors, it is important to identify and understand the broader scope of patient-defined adverse

406. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - Medical Care Visits Due to Adverse Effects of Medical Care Adult ambulatory medical care visits due … to adverse effects of medical care per 1,000 population, by race, stratified by sex, United States, … Importance: Adverse effects of medical care can arise from medical and surgical procedures as well … as from adverse drug reactions. … Providers treating adverse events in outpatient settings may include office-based physicians, hospital

407. Analyzing Big Datasets to Improve Healthcare Quality, Equity | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-hernandez-boussard.html
     April 01, 2024 - her career to analyzing “clinical big data” to identify quality and safety issues that can result in adverse … datasets on safety events, including AHRQ’s Healthcare Cost and Utilization Project (HCUP), she profiled adverse … Hernandez-Boussard also examined factors that could contribute to adverse events such as hospital surgical … Her research focuses on older patients and aims to mitigate the risk of adverse outcomes related to postoperative

408. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/hac-rates_2019.html
     July 01, 2020 - (PDF, 11.1 MB) Text Description: National efforts to reduce hospital-acquired conditions such as adverse … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease.

409. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
     January 01, 2024 - event compared to conditions when patients suffered moderate or severe outcomes as a result of an … events compared to no adverse outcome. … event occurred compared to moderate to severe events. … The conversation then proceeded to: how did this event or subsequent events make you feel? … at his shoes---being uncomfortable rather than forthright and direct in his acknowledgment of the event

410. Toolkit Implementation Guide for Acute Care Antibiotic Stewardship Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/acute_care_implementation_guide.pdf
     November 01, 2019 - assist with these discussions between ASPs and frontline staff: o “Identifying Antibiotic-Associated Adverse … on units for frontline providers to complete when they identify a potential antibiotic-associated adverse … event. … o “Learning From Antibiotic-Associated Adverse Events Form” is similar to a root cause analysis form … be completed during structured meetings to guide strategies to prevent future antibiotic-associated adverse

411. Impact of Staff-Led Safety Walk Rounds (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
     March 05, 2008 - During rounds, members of the group asked questions about near misses, adverse events, and system issues … • Cumbersome event reporting system for physicians (a user-friendly format already existed for nurses … • New forms and additional venues for reporting near misses and adverse events. … rounds, members of Team Safety noticed that few staff members knew how to report a near miss or actual event … Is there anything that could be done to prevent the next adverse event or to address your safety concern

412. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
     January 01, 2017 - Slide 10 Safety SAY: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 13 Adverse Effects SAY: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The event rates ranged from 2.3 to 8.7 per 100 patients.

413. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
     April 01, 2025 - Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients. … Patient record review of the incidence, consequences, and causes of diagnostic adverse events. … Sentinel Event.  https://www.jointcommission.org/resources/sentinel-event/ .

414. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
     May 01, 2016 - event disclosure, and dispute resolution, with the joint aims of (1) putting patient safety first by … Clinician responses were more varied and were affected by type of adverse event, but they did agree … drug event (ADE), the severity of the ADE (i.e., serious, significant, minor), the potential health … event. … Clinician responses were more varied and were affected by type of adverse event, but clinicians did

415. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - event disclosure, and dispute resolution, with the joint aims of (1) putting patient safety first by … Clinician responses were more varied and were affected by type of adverse event, but they did agree … drug event (ADE), the severity of the ADE (i.e., serious, significant, minor), the potential health … event. … Clinician responses were more varied and were affected by type of adverse event, but clinicians did

416. Final Progress Report: Quality of bag mask ventilation in critically ill children (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/nishisaki-report.pdf
     January 01, 2024 - Desaturation (SpO2<80%) or adverse TIAEs occurred in 5/20 (25%) of children with high-quality breath … Key Words mask ventilation, quality, child, critically ill, adverse events, oxygen desaturation … We identified and reported that 20% of TI are associated with adverse TI-associated events (TIAEs … Implementation of a multidisciplinary checklist decreased these event rates by only 4% since 2013 … Desaturation (SpO2<80%) or adverse TIAEs occurred in 5/20 (25%) of children with high-quality breath

417. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - 95% confidence interval, 0.28 to 0.55; P, 0.001) and a significantly lower risk of grade 3 or higher adverse … compare these between the intervention and control cohorts. • Measure the impact of med errors and adverse … Although contemporary immunosuppression is extremely effective at preventing rejection, adverse drug … Therefore, early recognition of adverse drug events in kidney transplant recipients will likely help … AE type and severity were defined using the Common Terminology Criteria for Adverse Events.

418. Practice-Based Research Networks (PBRNs) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/PBRN/pbrn.html
     September 01, 2018 - Effective approaches for facilitating patient self-management during a pandemic influenza event. … Field testing of a new ambulatory care electronic Medication Errors and Adverse Drug Events Reporting

419. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4h_combo_psi11-postoprespfailure-bestpractices.pdf
     May 20, 2016 - regarding the definition of true postoperative respiratory failure, it still remains an important patient adverse … event. … at increased risk for postoperative respiratory failure to better prepare clinicians to anticipate adverse

420. Rapidresponse Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
     May 01, 2017 - responding and expectations for the response, uniform expectations for documentation of the rapid response event … An event that requires a team response. … This principle calls for L&D unit teams to evaluate their processes and learn from adverse events, errors … The L&D unit can decide its approach to learning from defects based on seriousness of event, expertise … Consider these factors: · Unit data suggesting adverse events or near misses that may have been minimized