Results

Total Results: 1,789 records

Showing results for "adverse event".
Users also searched for: patient safety indicators

461. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - /sentinel-event-alert- newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … Patient Safety Primer: Medication Errors and Adverse Drug Events 18. Person-Centered Care 19.

462. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
     June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form Changing the System 12 What Happened? … Imagine the world as they did when the event occurred. 13 Changing the System 13 Why Did It Happen … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.   … Completion Guide for the Four Moments of Antibiotic Decision Making Form Learning From Antibiotic-Associated Adverse

463. AHRQ's Patient Safety Culture Survey Used to Set Baselines for Improvements at Chicago Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0609.html
     October 01, 2014 - Importantly, the survey also highlighted that staff were more uncomfortable with filing reports of adverse … team targeted its initiatives to address three specific dimensions of patient safety: reporting of adverse … events, handoffs and communication, and feedback and awareness of adverse events.

464. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
     April 01, 2022 - checklists, and create independent checks for key processes, we improve our ability to reduce the risks of adverse … One of these is adverse event reporting systems which are common in hospitals.  … Slide 12 The CLABSI and CAUTI Learn From Defects tools and other event reporting tools, such as the … CLABSI and CAUTI Event Report tools, provide a structured approach to help your teams identify system … Slide 13 The event report tool is designed to be used as a guide through the initial investigation

465. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
     January 01, 2003 - definitions of iatrogenic events related to medications.22 A medication error is defined as any preventable event … drug events, and adverse drug reactions. … Variations in adverse event and error operational definitions used by acute care hospitals in Iowa ( … Adverse Drug Prevention Study Group. The costs of adverse drug events in hospitalized patients. … Adverse drug events in hospitalized patients.

466. Final Progress Report: Clinical importance of the drug interaction between statins and CYP3A inhibitors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/strom-report.pdf
     January 01, 2024 - .31 Inclusion/exclusion criteria We assembled statin-naïve cohorts with no history of the outcome event … event. … We searched physician comments associated with each READ code event. … Read code-based events, in which additional physician comments supported the suspected event, were … Safety profile of rosuvastatin: Results of a prescription-event monitoring study of 11680 patients.

467. Situation Monitoring: Obstetric Hemorrhage (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring-speaker-notes.pdf
     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?

468. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/about/patient-safety-culture.html
     June 01, 2024 - rates. 2 Hospitals with more positive SOPS scores had: Lower rates of in-hospital complications or adverse … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.

469. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     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 to … We’re used to thinking about event reporting systems, liability claims, sentinel events, and mortality

470. Final Progress Report: Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/wei-report.pdf
     January 01, 2024 - exposure --- and risk for ORAEs by flexibly modeling the exposure at varying proximities to the event … non-benzodiazepines, anticonvulsants, antidepressants, antipsychotics, and anxiolytics, in the 6 months before the event … Prognostic factors were measured in the 6 months before the event date for cases or matched date for … approved for use in the US between 2011 and 2018 were captured from the Medicare Part D Prescription Event … Prescription opioid exposures and adverse outcomes among older adults.

471. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/areas/improve-discharge.html
     August 01, 2024 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … AHRQ Toolkit To Improve Medication Reconciliation Across Care Settings Six New Jersey Hospitals Reduce Adverse … Patient Safety and Team Communication Through Daily Huddles AHRQ PSNet Primer: Medication Errors and Adverse

472. Presentation: Science of Improving Patient Safety and Identifying Defects
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
     December 01, 2017 - In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … AHRQ Safety Program for Surgery – Onboarding SAY: Simply put, a defect is any clinical or operational event … Event reporting systems, liability claims, sentinel events, morbidity and mortality conferences Perioperative … We’re used to thinking about event reporting systems, liability claims, sentinel events, and mortality

473. Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
     January 01, 2025 - charting, concerns about staff training, coordination of care, patient and staff safety, reporting adverse … Treatment for Substance Abuse, 1P20HS017137 PI: Bentson McFarland, MD, PhD 6  Reporting Adverse … Self-Disclosing a Serious Event If you committed an error resulting in serious event for the client … (circle all that apply) Near Miss  Minor, temporary event  Minor, permanent event Major, temporary  … event  Major, permanent event  Serious event I don’t know 8.

474. Patient and Family Engagement in Primary Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/interventions/index.html
     June 01, 2023 - These tools will also help to identify risks for an adverse drug event, such as overdosing, underdosing

475. INSTRUCTIONS: Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
     January 01, 2009 - event avoided. … The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … The cost of nurse-sensitive adverse events. … The costs and savings associated with prevention of adverse events by critical care nurses. … event over time.

476. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Further, 13.6 percent of the adverse events led to the death of the patient. … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent … Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients.

477. The Science of Improving Patient Safety and Identifying Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
     December 01, 2017 - Surgery is linked to 50% of all hospital adverse events. … Most hospital adverse events are AVOIDABLE. Slide 6: How Do These Errors Happen? … Slide 16: Communication Breakdowns 6 Images: Four bar graphs showing root causes of adverse events … In each graph, communication is the most common root cause of each event.  … Event reporting systems, liability claims, sentinel events, morbidity and mortality conferences.

478. Study Finds More Health Risks for Children With Intellectual and Developmental Disabilities | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/950.html
     March 01, 2025 - Adverse events involving telehealth in the Veterans Health Administration . … The event will be sponsored by AHRQ’s National Center for Excellence in Primary Care Research . … Access more information , including how to register for the event and access recordings of previous

479. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
     April 01, 2023 - Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … a multi-disciplinary team approach, known as Root Cause Analysis (RCA) to study healthcare-related adverse … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event.

480. Creating a Safe Medicine List: Patient Information/Reminder Flyer (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
     June 02, 2025 - . ■ Answer your questions. 1 in 9 emergency department admissions are related to an adverse drug … event.