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Showing results for "adverse event".
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9021. Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. | PSNet
      psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va
      July 14, 2021 - July 14, 2021 Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced … October 12, 2022 Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced … April 29, 2020 Defense Health Agency Should Improve Tracking of Serious Adverse Medical

9022. Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams. | PSNet
      psnet.ahrq.gov/issue/organizational-perspectives-nurse-executives-15-hospitals-impact-and-effectiveness-rapid
      August 03, 2022 - January 23, 2017 Rates of medical errors and preventable adverse events among hospitalized … May 23, 2012 Intrahospital transport to the radiology department: risk for adverse events … More About The Topic Hospitals Nurse Managers Nurse Care Epidemiology of Errors and Adverse

9023. Effects of fatigue on anaesthetist well-being and patient safety: a narrative review. | PSNet
      psnet.ahrq.gov/issue/effects-fatigue-anaesthetist-well-being-and-patient-safety-narrative-review
      June 28, 2023 - July 12, 2019 Relationship between in-hospital adverse events and hospital performance … August 29, 2018 Analysis of hospital-level readmission rates and variation in adverse … June 22, 2022 How different countries respond to adverse events whilst patients' rights

9024. Perioperative patient safety recommendations: systematic review of clinical practice guidelines. | PSNet
      psnet.ahrq.gov/issue/perioperative-patient-safety-recommendations-systematic-review-clinical-practice-guidelines
      January 08, 2025 - January 8, 2025 Predictive power of the "trigger tool" for the detection of adverse events … Inappropriate hospital admission as a risk factor for the subsequent development of adverse … March 8, 2023 Potentially inappropriate medication administration is associated with adverse

9025. Medication safety in the neonatal intensive care unit: big measures for our smallest patients. | PSNet
      psnet.ahrq.gov/issue/medication-safety-neonatal-intensive-care-unit-big-measures-our-smallest-patients
      September 18, 2024 - February 17, 2011 Surgeon and surgical trainee experiences after adverse patient events … Effectiveness of a barcode medication administration system in reducing preventable adverse … Physicians Information Professionals Neonatology and Intensive Care Medication Errors/Preventable Adverse

9026. Safe implementation of standard concentration infusions in paediatric intensive care. | PSNet
      psnet.ahrq.gov/issue/safe-implementation-standard-concentration-infusions-paediatric-intensive-care
      June 17, 2014 - June 17, 2014 Predictive power of the "trigger tool" for the detection of adverse events … Inappropriate hospital admission as a risk factor for the subsequent development of adverse … View More Related Resources Implementing strategies to identify and mitigate adverse

9027. Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas. | PSNet
      psnet.ahrq.gov/issue/quality-care-concerns-and-facility-response-following-medical-emergency-va-southern-nevada
      July 13, 2022 - July 19, 2024 DOD Should Improve Its Process for Clinical Adverse Actions against Providers … March 20, 2024 Indian Health Service: Actions Needed to Improve Use of Data on Adverse … April 29, 2020 Defense Health Agency Should Improve Tracking of Serious Adverse Medical

9028. Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. | PSNet
      psnet.ahrq.gov/issue/vital-sign-abnormalities-rapid-response-and-adverse-outcomes-hospitalized-patients
      December 21, 2014 - Study Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized … Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. … Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients. … July 29, 2020 Automated identification of antibiotic overdoses and adverse drug events

9029. 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.

9030. 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.

9031. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - Most places do not have an explicit, concrete process by which they prioritize whether an event should … If it was blameworthy, the case would be placed on an administrative route where the facts of the event … that makes the front page of the local paper, it certainly is a very emotionally tinged and tragic event … Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Adverse … Conversation With… Harlan Krumholz, MD, SM April 1, 2018 Root cause analysis of adverse

9032. 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?

9033. 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

9034. 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

9035. 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

9036. 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-

9037. 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.

9038. 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

9039. 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

9040. 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