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161. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
     January 01, 2017 - Slide 10 Safety SAY: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 13 Adverse Effects SAY: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

162. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/resources/improve-discharge/index.html
     July 01, 2022 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … Toolkit To Improve Medication Reconciliation Across Care Settings Six New Jersey Hospitals Reduce Adverse … Patient Safety and Team Communication Through Daily Huddles AHRQ PSNet Primer: Medication Errors and Adverse … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety

163. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely … Because adverse events usually occur as a result of multiple failures, it is imperative that medical … events occur. … events. … events are not the result of one mistake.

164. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … By addressing common, preventable adverse events, a health care setting can become safer, thereby enhancing … More than three-fourths of PSOs offered analytical support for adverse events, and a similar share … “The Importance of Reporting Safety Events.” 2014. Analytic Support for Adverse Events. … Copyright 2015 ECRI Institute. www.ecri.org • Adverse events • Near misses • Hazards • Common Formats

165. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
     January 01, 2004 - The cost of adverse drug events in hospitalized patients. JAMA 1997;227(4):307–12. 7. … Detecting adverse events using information technology. JAMIA 2003c;10(2):115–28. 9. … Using information technology to screen for adverse drug events. … Identifying hospital admissions due to adverse drug events using a computer-based monitor. … Comparison of medication errors, adverse drug events, and intercepted errors Table 2.

166. Tennessee Hospital Association Uses AHRQ Tools To Boost Patient Safety, Saving $17 Million | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201702.html
     March 01, 2017 - AHRQ Social Media AHRQ Stats Impact Case Studies Blog Newsletter Events … Among others, these safety challenges included: Adverse drug events. … Obstetrical adverse events. Pressure ulcers. Surgical site infections. … Patient Safety Organization (PSO), Re-Engineered Discharge (RED) Topic(s): Adverse … Drug Events (ADE), Healthcare Costs, Healthcare-Associated Infections (HAIs), Quality of

167. Early Mobility in the Intensive Care Unit: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-fac-guide.html
     February 01, 2017 - Slide 11: Safety Say: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 14: Adverse Events Say: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

168. Chartbook on Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient

169. Regulation of Health Policy: Patient Safety and the States (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Illinois, New York, and Pennsylvania require that adverse events be disclosed to patients. … errors and preventable adverse events, and 3 years of adverse event reports to the New York Patient … JCAHO and New York are the only agencies that address the full range of adverse events, and JCAHO’s … Defining reportable adverse events: a guide for States tracking medical errors. … Patient safety: reporting of adverse events, NEJM 2002; 347(20):1,633–9. 39.

170. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
     November 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention provides a strategy for preventing adverse … events in nursing homes. … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early. … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

171. Data Resources | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/data/resources/index.html?page=0
     Data Resource Name Search   Filter by Topic Access to Care (4) Adverse … Events (1) Ambulatory (2) By Payer (2) By State (3) Children (3) Children (1) … HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about adverse … events and patient safety-related events in U.S. hospitals. … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries

172. AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/index.html
     July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Harms such as adverse drug events, healthcare-associated infections, falls, and obstetric adverse events … patient safety practices in eight categories encompassing commonly occurring care- and disease-specific adverse … events and associated systemic and contextual factors.

173. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - diagnostic breakdowns during transitions among clinical settings. 19 , 25 Assessing the impact of adverse … events on the health and well-being of patients. 26 Understanding the impact of diagnostic problems … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors … But patients and families do not describe adverse diagnostic events with such uniformity. … the sections that follow, we first synthesize what is known about patient/family reporting of safety events

174. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. 8 Develop a Measurement Strategy5 WHAT to measure Process … events.”

175. 2017Qdr-Patsafchartbook (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - drug event to warfarin (Adverse drug events) …  Procedure-related events.  Adverse drug events. … events associated with hip joint replacement, adverse events associated with knee joint replacement … events associated with hip joint replacement, adverse events associated with knee joint replacement … Events 30-Day Mortality for Colorectal Surgery Adverse Drug Events Adverse Events With Hypoglycemic

176. Toolkit Implementation Guide for Acute Care Antibiotic Stewardship Programs (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/acute_care_implementation_guide.pdf
     November 01, 2019 - events as well as first and second order problem solving approaches. … o “Learning From Antibiotic-Associated Adverse Events Form” is similar to a root cause analysis form … events. … changes.html https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/identifying-antibiotic-adverse-events-form.docx … https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx

177. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (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-Neuspiel_43.pdf
     March 05, 2008 - The IOM has called for a reporting system that includes both adverse events and near misses. … A physician- based voluntary reporting system for adverse events and medical errors. … Confidential clinician-reported surveillance of adverse events among medical inpatients. … Adverse drug events in primary care. N Engl J Med. 2003; 348: 1556-1564. 15. … Will, ideas, and execution: Their role in reducing adverse medication events.

178. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse Patient Safety

179. About the Toolkit Development | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Background Of the 3.9 million births in the United States each year, 2 percent are estimated to involve an adverse … and 70 percent of sentinel neonatal events. … inappropriate interventions, or interventions provided in an unsafe manner, also increases the risk of adverse … events on L&D units.

180. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home In October 2009, AHRQ launched … Hickson Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor … Bolkan Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital