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Showing results for "adverse events".
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121. Mod03-Gap-Analysis-Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
     April 01, 2016 - Identification and Analysis of Actual and Potential Adverse Events a. … Is there a process in place for identifying, managing, and analyzing adverse events, near miss events … Do staff have access to a system for reporting adverse events? c. … identifying, managing, and analyzing adverse events, near miss events, and unsafe conditions? … Do staff have access to a system for reporting adverse events?

122. Choosing an Intervention and Measuring Change | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
     June 01, 2021 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … The Staff Safety Assessment Form and the Learning from Antibiotic-Associated Adverse Events Form … Staff Safety Assessment Form (DOCX, 330.3 KB) Learning From Antibiotic-Associated Adverse Events Form

123. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - It is estimated that one in seven patients is affected by adverse events, and that as many as half of … Module 6 7 As referenced in Module 3, this diagram shows the distinction between adverse events and … errors, and recognizes that not all adverse events are medical errors, and not all medical errors are … adverse events. … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

124. Puh-Factraining-Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.pdf
     December 15, 2016 - Events SAY: There are four sets of On-Time reports to help prevent four adverse events: …  Commitment to work with a Facilitator to learn how to use the reports to prevent adverse events … The reports:  Focus on preventing adverse events.  Are proactive rather than reactive. …  Improve root cause analyses when adverse events occur. … Slide 5: Discussion Slide 6: On-Time Reports for Four Adverse Events Slide 7: Common Elements of On-Time

125. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - Results: Twenty-one cases (12 medical, 9 surgical) representing adverse events were presented at the … Adverse events triggering case selection included unexpected deaths (six), unplanned intubations (two … MM&I Results Twenty-one cases representing adverse events were presented in the MM&I conference series … Adverse events triggering case selection are listed in Table 2. … Adverse events triggering case presentations Case N Unexpected deaths 6 Unplanned intubation

126. What Exactly Is Patient Safety? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - The realization that adverse events often occur because of system breakdowns, not simply because of … Transparency and Learning The idea that adverse events could yield information was not new, but as it … The goal of the field of patient safety is to minimize adverse events and eliminate preventable harm … In this sense, patient safety espouses continuous cycles of learning, reporting of adverse events or … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 15.

127. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - as from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.

128. VI. Summary and Conclusions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
     May 01, 2016 - What was known after two decades of prior research is that adverse events, errors, and even near-miss … events can be identified, a nomenclature can be created to structure and catalog reports of such events … When adverse event reporting systems were first built, they did not receive many reports.  … It was not until the culture in hospitals changed around adverse event reporting that reports started … Overall, the number of reports received was disappointing, given the potential reservoir of adverse events

129. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
     March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … events were occurring in order to prevent them. … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features The QSRS: Offers an expanded array of adverse event measures. … Provides additional detail for the most frequently occurring events.

130. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
     November 01, 2017 - Obstetric Adverse Events (OBAE) An adverse maternal or fetal outcome that occurs during labor and/ … events included postpartum hemorrhage, preeclampsia/eclampsia, and anesthesia-related adverse events … adverse events as the end point. … events and the risk of death among women experiencing maternal adverse events. … ”[tiab] OR “adverse drug events”[tiab] OR “adverse drug reaction”[tiab] OR “adverse drug reactions”[

131. Improving Safety for Patients with Limited English Proficiency: TeamSTEPPS
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
     January 01, 2013 - know about patient safety and Limited English Proficiency (LEP) patients Identify common causes of adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Nearly 25 million people in the United States (8.6%) are defined as LEP and therefore at risk for adverse … Language proficiency and adverse events in U.S. hospitals: a pilot study. … 0.5 Sheet1 Adverse Event Characteristic English Speaking N (%) Limited English Proficient N (%) P-value

132. Analyzing Big Datasets to Improve Healthcare Quality, Equity | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-hernandez-boussard.html
     April 01, 2024 - her career to analyzing “clinical big data” to identify quality and safety issues that can result in adverse … events. … ), she profiled adverse events for various surgical events such as heart bypass surgery, breast reconstruction … Hernandez-Boussard also examined factors that could contribute to adverse events such as hospital surgical … Her research focuses on older patients and aims to mitigate the risk of adverse outcomes related to postoperative

133. Appendix | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhac2013-ap1.html
     December 01, 2014 - Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse … Catheters 9,200 0.28 Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse … Events PSI (2012) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) … 2013) Femoral Artery Puncture for Catheter Angiographic Procedures 59,000 1.8 MPSMS (2013) Adverse … Events Associated With Hip Joint Replacements 21,000 0.63 MPSMS (2013) Adverse Events Associated

134. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
     November 30, 2010 - at High Risk of Adverse Drug Events: Study Methods Andrew L. … Six hundred subjects at high risk of adverse drug events (ADEs) will be enrolled across three study … The costs associated with adverse drug events among older adults in the ambulatory setting. … Risk factors for adverse drug events among older adults in the ambulatory setting. … Strategies for detecting adverse drug events among older persons in the ambulatory setting.

135. Disclosure Checklist | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.  

136. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - In 1998 there were 28 (14 percent) adverse events (patient minimally effected) and 25 (9 percent) in … 2001, compared with a rate of 86.00 near misses and 14.00 adverse events in 1998 (Table 1). … Incident type 1998 2001 Near misses 86.00 90.94 Adverse events 14.00 9.06 Figure 3. … Potential identifiability and preventability of adverse events using information systems. … Rate of near misses and adverse events per 100 incident Table 2.

137. Data Measures Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
     January 01, 2017 - Event Incidence Rate Numerator Total number of adverse events which occurred during mobilization … Events Numerator Total number of adverse events in each of the 25 categories which occurred during … /Trach & Mech Vent were marked “Y” Example Display top 10 adverse events. … event occur Target Low adverse event rate Mobility NOT Intubated: Distribution of Adverse Events … Events (cont) Example Display top 10 adverse events.

138. Prologue: Technology and Medication Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
     July 25, 2008 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … drug events; reduce costs through streamlining processes and providing more targeted, efficient care … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … drug events.

139. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of

140. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Detecting adverse events for patient safety research: a review of current methodologies. … Measuring errors and adverse events in health care. J Gen Intern Med  2003;18(1):61-7. … Lessons from a patient partnership intervention to prevent adverse drug events. … Computerized surveillance of adverse drug events in hospital patients. … Adverse events during hospitalization: results of a patient survey.