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Showing results for "adverse event".
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441. Recommended Infection Prevention Components of Quality Assessment and Performance Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/recommendedinfectionprev-components.pdf
     June 02, 2025 - areas should be continuously monitored, with analysis of the available data, prompt recognition of adverse … The Centers for Disease Control (CDC) National Healthcare Safety Network dialysis event rates should

442. Situation Monitoring: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring.pptx
     July 01, 2023 - First, as an after-action review of a patient case, especially one involving an adverse event like severe … Debriefing each case, whether the case went smoothly or there were adverse events associated with the … these types of debriefs will be held in the Reporting and Systems Learning stage in response to an adverse … What system issues contributed to how we handled the event? … What system issues contributed to how we handled the event?

443. AHRQ HAC 2015 Interim Data Graphic V03C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-infographic-2015.pdf
     January 01, 2015 - 21%21% LIVES SAVEDLIVES SAVED 125,000125,000 IN SAVINGSIN SAVINGS $28 BILLION $28 BILLION FEWER ADVERSE … EVENTS FEWER ADVERSE EVENTS 3 MILLION3 MILLION From 2010–2015, more than 3 million hospital-acquired

444. Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/guide.docx
     March 01, 2017 - Communication and Engaging the Family Addressing Challenges and Barriers · Slides 27–28 Communicating Adverse … All 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

445. Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_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.

446. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     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.

447. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
     February 21, 2008 - One in five hospital discharges is complicated by an adverse event (AE) within 30 days, many of which … event (AE) within 30 days, often leading to an emergency department visit and/or rehospitalization … Medical Errors and Adverse Events at Hospital Discharge Errors and Adverse Events Are Common on Both … The cost of treating an adverse drug event in a hospital averages $3,244 to $5,857 per case.47, 48, … 49, 50 3 Adverse Drug Events: Common, Serious, and Costly Adverse drug events (ADEs) are the

448. Patient and Family Engagement in the Surgical Environment Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-slides.html
     May 01, 2017 - Fear of litigation Transparency and adverse events, compliance with patient privacy laws. … Document event in the medical record. Next Steps Investigation. … Organizations should be prepared to respond and communicate proactively when adverse events occur. … PS 105: Patient Safety and Communicating with Patients After an Adverse Event (updated August 15, 2016 … , to Responding to Adverse Events).

449. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2014.html
     January 01, 2018 - safety has occurred during a period of concerted attention by hospitals throughout the country to reduce adverse … About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … paper by Furukawa, et al. ( Journal of Patient Safety , in press) indicated that in 2012 and 2013, adverse … Although the paper did not study trends in EHR adoption or trends in adverse event rates, one may hypothesize

450. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - event or harm. … Clinical processes can be fraught with errors without leading to an adverse event, but morbidity and … Our studies suggested that the final location of syringes and vials in each event varies and includes … Of the 94 respondents, 43.6% reported experiencing a near-miss or patient-harm event. … Biro et al. – Data Variability in Adverse Event Reporting Systems and the Potential Role of Interface

451. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Human Services’ Office of the Inspector General, states that “patients may be experiencing unnecessary adverse … Of the preventable adverse drug events in nursing homes, 70 percent occurred at the monitoring stage … drug event (ADE). … Epidemiology of adverse drug events in the nursing home setting. Drugs Aging 1995;7:203–11. 17. … Incidence and preventability of adverse drug events in nursing homes.

452. Final Progress Report: Transitional Care Medication Safety and Reducing Medical Liability: Closing the Chasm (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/corbett-report.pdf
     January 01, 2024 - Key Words: transitional care; medication safety; medication discrepancy; medication errors; adverse … can be integrated into transitional care to reduce medication discrepancies and associated errors and adverse … Research indicates that rates of adverse drug events (ADEs) in ambulatory care may be up to four times … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Adverse drug events in ambulatory care. New England Journal of Medicine, 348, 1556–1564.

453. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … This evaluation provides the means to identify interventions that can reduce the risk of future adverse … Say: Simply put, a defect is any clinical or operational event or situation that you would not want … We’re used to thinking about event reporting systems, liability claims, sentinel events, and mortality

454. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
     August 01, 2022 - After the resolution of a CANDOR event, information is fed into an organization’s performance improvement … These may include a checklist to follow after an event. … Event Reporting, Investigation, and Analysis Team. Resolution Team. … time, the organization must continue to encourage frontline staff to report CANDOR events and other adverse … Think about a patient story involving a CANDOR event.

455. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
     May 01, 2017 - 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, … The L&D unit can decide its approach to learning from defects based on seriousness of event, expertise … Consider these factors: o Unit data suggesting adverse events or near misses that may have been

456. Situation Monitoring: Severe Hypertension - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring.pptx
     July 01, 2023 - First, as an after-action review of a patient case, especially one involving an adverse event like severe … Debriefing each case, whether the case went smoothly or there were adverse events associated with the … these types of debriefs will be held in the Reporting and Systems Learning stage in response to an adverse … What system issues contributed to our handling of the event? … What system issues contributed to our handling of the event?

457. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     June 01, 2025 - patient safety practices in eight categories encompassing commonly occurring care and disease specific adverse … Table of Contents Adverse Drug Events (ADEs): General Medication Topics ADEs: Harms Due to Anticoagulants … ADEs: Harms Due to Diabetic Agents ADEs: Reducing Adverse Drug Events in Older Adults ADEs: Harms Due … Drug Event Detection and Alerts Summary of Evidence (Not reviewed) (Not reviewed) (Not reviewed) Unit-Dose … Drug Events Summary of Evidence Summary of Evidence (Not reviewed) (Not reviewed) Reducing Adverse Drug

458. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.docx
     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.

459. Black History Month | Agency for Healthcare Research and Quality
     www.ahrq.gov/priority-populations/observances/bhm/index.html
     February 01, 2025 - African-Americans (PDF, 364 KB) Patient Safety Network (PSNet) African American COVID-19 mortality: a sentinel event … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital

460. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - PEERs facilitates the discovery, management, and eventual reduction of adverse events. … Data are gathered about the type of event, the location of the event, contributing factors, injuries … prevention of the event. … The Report Management Tool is used to manage event reports, analyze event classes and the cause of events … This individual is able to view and manage all medication or adverse drug events reported in PEERs without