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Showing results for "adverse event".
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8801. Tune-in and time-out: toward surgeon-led prevention of "never" events. | PSNet
      psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-never-events
      July 24, 2024 - Though nurses felt surgeon-led time outs are valuable and lead to fewer adverse events, 94% of them reported … Related Resources From the Same Author(s) A human right-based approach to dealing with adverse

8802. Methods Guide for Comparative Effectiveness Reviews - Expanded Guidance on Selected Quantitative Synthesis Topics (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/quantitative-synthesis-expanded-methods_methods.pdf
      March 01, 2013 - If a composite outcome is time-to-event, it takes the value of the time until the first event. … For example, a CER on second-generation antidepressants compared discontinuation due to adverse events … risk increase, that is, venlafaxine had a 36 percent higher risk of causing discontinuation due to adverse … Time to Event Data and Count Data Hazard ratio (HR) is the measure typically used for time to event … in the control group) if the event rate is not available.

8803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33602/psn-pdf
      March 15, 2025 - This approach takes the stance that adverse events occur due to poorly designed systems, which allow … Analysis of adverse events in many industries has shown that isolated individual errors less commonly … The growing prevalence of burnout among clinicians has been linked to adverse patient outcomes and is … There are few studies on the prevalence of adverse events or errors due to performance issues among … safety should not only seek to define clinician factors that predispose to performance issues and adverse

8804. Mistaking error. | PSNet
      psnet.ahrq.gov/issue/mistaking-error
      July 06, 2011 - February 3, 2021 Health care professionals as second victims after adverse events: a … April 10, 2019 Disclosing adverse events to patients: international norms and trends.

8805. 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

8806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40824/psn-pdf
      October 05, 2011 - paediatric A comprehensive quality improvement intervention resulted in a significant reduction in adverse

8807. 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?

8808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42114/psn-pdf
      March 20, 2013 - hospital-initiated-transitional-care-interventions-patient-safety-strategy- systematic-review Despite an intense policy focus on preventing readmissions and adverse … day-readmissions-structured-case-series-across-18-hospitals https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge

8809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41067/psn-pdf
      February 10, 2012 - However, this analysis of data from Florida and Alabama—states with mandatory reporting systems for adverse … events in office-based surgery—found few overall adverse events among medically necessary procedures

8810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841142/psn-pdf
      December 07, 2022 - experience-hospital-initiated-medication-changes-older-people-multimorbidity- multicentre Polypharmacy can place older adults at increased risk of adverse … experience-hospital-initiated-medication-changes-older-people-multimorbidity-multicentre https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

8811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43856/psn-pdf
      March 18, 2015 - identified focused primarily on environmental factors and few discussed how behaviors may contribute to adverse … keeping-patients-safe-transforming-work-environment-nurses https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

8812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37181/psn-pdf
      October 06, 2011 - Inter-rater reliability of a classification system for hospital adverse drug event reports. … Inter-rater reliability of a classification system for hospital adverse drug event reports. … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports

8813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44217/psn-pdf
      November 10, 2015 - Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug … event triggers designed for the outpatient setting. … event triggers designed for the outpatient setting. … Trigger tools have been shown to be an efficient way to screen for adverse events. … This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient

8814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36895/psn-pdf
      March 10, 2011 - A systematic review of the performance characteristics of clinical event monitor signals used to detect … adverse drug events in the hospital setting. … A systematic review of the performance characteristics of clinical event monitor signals used to detect … adverse drug events in the hospital setting. … The authors analyzed the literature and identified laboratory and pharmacy triggers used to detect adverse

8815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44635/psn-pdf
      June 21, 2016 - Evaluation of perioperative medication errors and adverse drug events. … At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed … drug event; 80% of these errors were deemed preventable. … There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists … ://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention

8816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73473/psn-pdf
      January 01, 2022 - Improving safety recommendations before implementation: a simulation-based event analysis to optimize … interventions designed to prevent recurrence of adverse events. … Improving safety recommendations before implementation: a simulation-based event analysis to optimize … interventions designed to prevent recurrence of adverse events. … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-

8817. Data Collection Form | Digital Healthcare Research
      digital.ahrq.gov/document-type/data-collection-form
      January 01, 2023 - ADE Incident Identification Form Description This form identifies an adverse … drug event using data reported by a clinician. … Chart Review Form Description This is a chart review form for an adverse … drug event (ADE) study. … drug event study.

8818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43567/psn-pdf
      October 21, 2016 - National Action Plan for Adverse Drug Event Prevention. … https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention This national action … aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse … common usage and their very high potential to cause clinically significant, preventable, and measurable adverse … https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention https://psnet.ahrq.gov

8819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35023/psn-pdf
      March 04, 2011 - Building a framework for trust: critical event analysis of deaths in surgical care. … Building a framework for trust: critical event analysis of deaths in surgical care. … commentary discusses the role of the Scottish Audit of Surgical Mortality (SASM) on trends in adverse … Findings include a decrease over time in the percentage of deaths for which adverse events in management … conclude that voluntary mortality audits may lead to important changes in practice and focusing on adverse

8820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45468/psn-pdf
      October 11, 2017 - Identification and characterization of adverse drug events in primary care. … Identification and Characterization of Adverse Drug Events in Primary Care. … https://psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care Adverse … drug event during a change in medications. … Less than 10% of patients experienced an adverse drug event, which the authors conclude represents an