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Showing results for "adverse event".
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421. Rapid Response for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
     July 01, 2023 - 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

422. Module 4: Teamwork and Communication: Material Use Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/guide.html
     March 01, 2017 - Engaging the Family Addressing Challenges and Barriers Slides 27-28 Communicating Adverse … staff, including administrators and frontline staff; residents and families Topic: Communicating Adverse … work with facility leaders and administrators to share information with residents/families when an event

423. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (   PDF , 109 KB ) … Voluntary Adverse Event Reporting in Rural Hospitals  (   PDF , 478 KB ) Charles P. … Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy  (   PDF , 133 KB ) … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance   … News Media and Health Care Providers at the Crossroads of Medical Adverse Events (   PDF , 129 KB )

424. AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/index.html
     July 01, 2023 - Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse

425. Data Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/resources/index.html?page=0
     HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about adverse … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries

426. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Consensus building for development of outpatient adverse drug event triggers. … Computerized surveillance of adverse drug events in hospital patients. … event analysis. … Integrating natural language processing expertise with patient safety event review committees to improve … Adverse events during hospitalization: results of a patient survey.

427. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Adverse event*: Any injury caused by medical care. … Identifying something as an adverse event does not imply “error,” “negligence,” or poor quality care … The one hospital that stratified their adverse event data by language found clusters of adverse events …  A field for whether a hospital interpreter was present at the time of the adverse event or was used … event

428. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
     September 01, 2019 - event happens. … (F3R) Hospital management seems interested in patient safety only after an adverse event happens. … (G1) (No event reports, 1 to 2, 3 to 5, 6 to 10, 11 to 20, 21 event reports or more) 45% 44% 1% … event happens. … (F3R) Hospital management seems interested in patient safety only after an adverse event happens

429. Return on Investment Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - event avoided. … The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … The costs and savings associated with prevention of adverse events by critical care nurses. … allows users to track the change in rate of any type of adverse event over time.

430. Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2023-virtual-research-meeting-summary-patient-experience.pdf
     January 01, 2023 - However, compared to White adults, Black adults were 64 percent more likely to report an adverse event … , often absent Immediate Communication with patient, family Deny/defend Transparent, ongoing Event … Black participants were 64% more likely to report a preventable adverse event (i.e., repeat test, drug-drug … patient safety event rates remain stubbornly high in hospitals. … We describe an often untapped source of safety event reporting—patients and family members of hospitalized

431. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - diagnostic breakdowns during transitions among clinical settings. 19 , 25 Assessing the impact of adverse … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors … But patients and families do not describe adverse diagnostic events with such uniformity.

432. Choosing an Intervention and Measuring Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
     June 01, 2021 - The Staff Safety Assessment Form and the Learning from Antibiotic-Associated Adverse Events Form … Staff Safety Assessment Form (DOCX, 330.3 KB) Learning From Antibiotic-Associated Adverse Events Form

433. Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/sands.html
     August 01, 2017 - Its goals are to (1) proactively identify adverse events, (2) differentiate between injuries caused by … The DA&O approach to adverse events initially did not gain momentum as a risk management practice and … event to a patient and guidance on what to expect from the patient in that conversation. … event to make the program successful (e.g., where resources are located, how to document the disclosure … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals. 

434. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
     May 01, 2023 - Calls And Hazardous Conditions https://psnet.ahrq.gov/resources/resource/32494 This new sentinel event … 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. … news-and-multimedia/fact-sheets/facts-about-do- not-use-list/ In 2001, The Joint Commission issued a Sentinel Event … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

435. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Hickson Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor … Bolkan Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital

436. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
     January 01, 2007 - peer review to help determine if the event might have been prevented. … It is rarely cost effective or desirable to change systems in response to every single event. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … outcome 1 = Minor adverse outcome (non-serious effect, not requiring treatment) 2 = Moderate adverse … outcome (significant effect, requiring treatment) 3 = Serious adverse outcome (permanent adverse effects

437. 124-Cusp-Science-Safety-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
     April 01, 2025 - Cheese Model,” which is now widely used to understand system failures and why sometimes they lead to an adverse … event and sometimes they don’t. … It is their action that enables the event to occur. … In other words, active failures are the adverse events we are used to thinking about and attempt to avoid … These adverse outcomes are our “defects”—the events that occur and we don’t want them to happen again

438. Strategy 4: IDEA Discharge Planning (Tool 1) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
     January 01, 2010 - for engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … event within 30 days of discharge. … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Remember that discharge is not a one-time event but a process that takes place throughout the hospital … Discharge planning should be an ongoing process throughout the stay, not a one-time event.

439. Strategy 4: IDEA Discharge Planning (Tool 1) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_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 … Remember that discharge is not a one-time event but a process that takes place throughout the hospital … Discharge planning should be an ongoing process throughout the stay, not a one-time event.

440. Final Progress Report: Society for Pediatric Sedation Consensus Meeting: Great Expectations— Defining Quality in Pediatric Sedation (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/connors-report.pdf
     January 01, 2025 - Adverse events were not uniformly defined and wide ranges of occurrence of adverse events were described … How to define safety in terms of definitions of what constitutes an adverse event? 4 a. … If the patient experiences a brief monitored event but no lasting effects, is the event adverse? … Does the magnitude of a monitored response change constitute an adverse event at a particular level … the discussion toward rescue skills required rather than simply monitoring rates of any particular event