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Showing results for "adverse event".
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9881. Kidney-Disease-Medicine Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/kidney-disease-medicine_executive.pdf
      January 01, 2012 - CKD, the kidneys are damaged and/ or cannot filter blood normally.1 CKD increases the risk for many adverse … • Few trials reported adverse events. … • Although limitations in reporting impeded the quantitative synthesis of withdrawal and adverse … positive tests (for progression); medication adverse effects; increased medical visits; increased … CKD Treatment Harms Knowledge Gaps Withdrawals and adverse events were reported in few RCTs.

9882. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
      May 01, 2017 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … Defects (CUSP Element) Key Perinatal Safety Elements Examples Debrief and analyze near misses and adverse … · Informal debriefings by clinical team immediately following event using an approach that does not … www.safehealthcareforeverywoman.org · Resource name: Process for Reviewing Severe Maternal Morbidity Event … Sample scenario: · Shoulder dystocia · Shoulder dystocia training can be effective at reducing adverse

9883. Using Barcode Medication Administration to Improve Quality and Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/lesson/09-0023-ef-bcma.pdf
      December 01, 2008 - Adverse Drug Events Prevention Study Group. … The costs of adverse drug events in hospitalized patients. JAMA 1997;227: 307-11. 4. … Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34. 6. … Systems analysis of adverse drug events. JAMA 1995;274:35-43. 8. … Effect of bar-code technology on the incidence of medication dispensing errors and potential adverse

9884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - The Commentary Adverse events occur during 3%-39% of all surgical admissions, with the operating room … if ever, used to investigate intra-operative occurrences that don't rise to the level of "sentinel event … The incidence and nature of surgical adverse events in Colorado and Utah in 1992. … Incidence of adverse events and negligence in hospitalized patients. … An alternative strategy for studying adverse events in medical care.

9885. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - Following treatment of LAST, the patient should be observed for at least 2 hours after a CNS event and … for 4-6 hours after a cardiovascular event, but clinical decision making should depend on the severity … Sentinel Event Data – Root Causes by Event Type, 2004 – 2014. … May 8, 2024 Prescription opioid dose reductions and potential adverse events: a multi-site … November 4, 2020 When safety event reporting is seen as punitive: "I've been PSN-ed!"

9886. Transfer Troubles | PSNet
      psnet.ahrq.gov/web-mm/transfer-troubles
      December 29, 2014 - Understand the frequency of errors and adverse events in the transfer of patients between hospitals. … Describe how communication lapses can lead to errors and adverse events in the transfer of patients between … transfers, it has been shown that adverse events can occur in 1% to 34% of critical care transfers.( … 4,7,8 ) In one study, approximately 17% of the adverse events resulted in potential harm to patients … Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15:923-931.

9887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47674/psn-pdf
      December 19, 2018 - Family-centered rounds reduced both preventable and nonpreventable adverse events. … psnet.ahrq.gov/primer/patient-engagement-and-safety https://psnet.ahrq.gov/issue/can-we-rely-patients-reports-adverse-events

9888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38612/psn-pdf
      May 06, 2009 - assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety https://psnet.ahrq.gov/issue/adverse-drug-events-pediatric-outpatients … ismps-list-high-alert-medications-acute-care-settings https://psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events-children-and

9889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46424/psn-pdf
      March 20, 2018 - electronic-triggers-identify-delays-follow-mammography-harnessing-power-big- data-health-care Electronic triggers are critical tools for detecting adverse … primer/triggers-and-trigger-tools https://psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events

9890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38761/psn-pdf
      July 15, 2009 - effect-bar-code-assisted-medication-administration-medication-administration- errors-and Bar coding technology is being rapidly adopted as a mechanism to prevent adverse … effect-bar-code-assisted-medication-administration-medication-administration-errors-and https://psnet.ahrq.gov/issue/medication-dispensing-errors-and-potential-adverse-drug-events-and-after-implementing-bar

9891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48098/psn-pdf
      July 10, 2019 - how-often-do-prescribers-include-indications-drug-orders-analysis-4-million-outpatient https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events … https://psnet.ahrq.gov/issue/patient-safety-ambulatory-settings https://psnet.ahrq.gov/issue/adverse-drug-events-us-adult-ambulatory-medical-care

9892. ASHP guidelines on preventing medication errors in hospitals. | PSNet
      psnet.ahrq.gov/issue/ashp-guidelines-preventing-medication-errors-hospitals
      August 29, 2021 - March 9, 2011 Role of pharmacist counseling in preventing adverse drug events after hospitalization … Health Care Providers Hospital Pharmacy Medication Safety Medication Errors/Preventable Adverse

9893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40725/psn-pdf
      October 16, 2012 - association-icu-or-hospital-admission-unintentional-discontinuation-medications-chronic https://psnet.ahrq.gov/issue/incidence-and-severity-adverse-events-affecting-patients-after-discharge-hospital … https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge https://psnet.ahrq.gov

9894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47208/psn-pdf
      July 19, 2018 - 137 hospitals in the United States and Canada to reduce harm from hospital-acquired conditions and adverse … issue/impact-medicares-nonpayment-program-hospital-acquired-conditions https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

9895. AHRQ National Scorecard on Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/index.html
      July 01, 2020 - Condition Rate ( PDF , 237 KB) To improve how the Nation tracks its progress on reducing HACs and other adverse … This patient safety surveillance system will capture information about HACs and other adverse events

9896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45220/psn-pdf
      June 08, 2016 - Improved patient safety culture scores have been associated with reduced adverse events and better patient … surveys-patient-safety-culture https://psnet.ahrq.gov/issue/impact-comprehensive-patient-safety-strategy-obstetric-adverse-events

9897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45330/psn-pdf
      August 03, 2016 - Centers for Medicare and Medicaid Services, this secondary analysis examined the link between rates of adverse … Investigators found that hospitals with a greater aggregate rate of adverse events also had higher readmission

9898. 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

9899. 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

9900. 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