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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … management
Disruptive behavior and/or code of conduct
Investigation of occurrences (i.e., sentinel events … ___
Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse … or "harm" events
___
___
Organizational safety and/or quality plan
FMEAs or other
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - learning from defects for oxytocin administration include—
Debriefing and analyzing near misses and adverse … Having a process in place to review severe maternal or neonatal morbidity and mortality events. … key safety elements of learning from defects are the same as for oxytocin:
Debriefing near misses and adverse … events related to magnesium sulfate use. … Consider these factors:
· Unit data suggesting adverse events or near misses related to oxytocin, magnesium
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ahrqpubs.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Studies
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Events … hospitals and nursing homes (including skilled nursing facilities) to collect data for all types of adverse … events, near misses, and unsafe conditions. … Research suggests that adverse events affect patients with limited English proficiency more frequently … If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications
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ahrqpubs.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy3/index.html
December 01, 2017 - Studies
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Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors.
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ahrqpubs.ahrq.gov/patient-safety/reports/candor-demo-program/candor/demo-program/index.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … These projects sought to improve patient safety by measuring safety problems, characterizing adverse … events, and conducting clinical safety interventions.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse … of these could have been prevented
or ameliorated.1 Common post-discharge complications
include adverse … drug events, hospital-acquired infections,
and procedural complications.1 Many of these
complications … The
incidence and severity of adverse events affecting
patients after discharge from the hospital.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - for engaging patients and families in discharge planning
Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented
or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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ahrqpubs.ahrq.gov/topics/index.html?page=1
January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
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ahrqpubs.ahrq.gov/es/topics/index.html?page=1
January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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ahrqpubs.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
September 01, 2016 - for health care safety and quality in a variety of fields, including patient engagement, response to adverse … events, diagnostic error reduction, rapid response, and infection prevention, among others. … Safety Monitoring System, a nationwide surveillance project aimed at identifying the rates of specific adverse … events within the Medicare population. … paper, and led the AHRQ-Brigham medication safety HIT CERT CEDAR (Calling for Earlier Detection of Adverse
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ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/878.html
August 01, 2023 - Studies
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Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … (Source: JAMA Network Open , Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem … include:
Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse
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ahrqpubs.ahrq.gov/talkingquality/explain/share-info/highlight.html
September 01, 2019 - Studies
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Events … For example, in the next few years, we may see systems that enable patients to report on adverse events
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ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/821.html
June 01, 2022 - Studies
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Events … section
News
Newsroom
Blog
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AHRQ News Now
Events … Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia … Assessing adverse event reports of hysteroscopic sterilization device removal using natural language
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ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/803.html
March 01, 2022 - Studies
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Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … This included reductions in the use of fluoroquinolones, a class of antibiotics known to cause adverse … Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge
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ahrqpubs.ahrq.gov/topics/hospital-readmissions.html
January 01, 2012 - Studies
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Events … Readmissions and Adverse Events After Discharge
This Patient Safety Primer from AHRQ's Patient Safety
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
April 01, 2011 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … be prevented
Common complications post-discharge are adverse drug events, hospital-acquired infections … have been prevented or ameliorated.1
Common post-discharge complications include adverse drug events … The incidence and severity of adverse events affecting patients after discharge from the hospital. … events and prevent readmissions.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - fractures.3,9
Staff with requisite training and supplies available to respond to magnesium-related adverse … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to magnesium sulfate use … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events including respiratory depression
2.
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ahrqpubs.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
December 01, 2017 - Studies
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AHRQ Views
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Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … requires the successful transfer of information from clinicians to the patient and family to reduce adverse … events and prevent readmissions.