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digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
January 01, 2008 - Incidence of adverse events
and negligence in hospitalized patients. … The nature of adverse
events in hospitalized patients. … Medication Errors and
Adverse Drug Events in Pediatric Inpatients. … Relationship between medication errors and
adverse drug events. … Systems analysis of adverse drug
events. ADE Prevention Study Group.
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digital.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-record/annual-summary/2010
January 01, 2010 - HIV RNA, depression, anxiety, and quality of life; safety, such as documentation of drug allergies, adverse … events, and medication reconciliation; and utilization, such as office visits.
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digital.ahrq.gov/principal-investigator/sullivan-sean
January 01, 2023 - processes and human factors, and externally, on patient safety as measured by medication errors and adverse … drug events.
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digital.ahrq.gov/sites/default/files/docs/care-transitions-slides-052313.pdf
May 23, 2013 - & SEE – Technology for connectivity
15
Failures of Care Coordination
150,000 preventable adverse … drug events
($8 Billion wasted) nationwide each year
occur at the time of hospital admission
( … Stiell, et al., 2003)
1.5 Million preventable adverse events
annually nationwide following hospital … The Incidence and Severity of
Adverse Events Affecting Patients after Discharge from the Hospital. … events.
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digital.ahrq.gov/sites/default/files/docs/activity/2011_017786_ritchie_pdf_3.pdf
January 01, 2011 - Summary: When complex patients transition from hospital to home-based care they are at high risk for
adverse … events, including medical error. … several updates to the data collection tools including: 1) developed a specific coding
schema to label events
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digital.ahrq.gov/sites/default/files/docs/page/modeling-risk-reduction-interventions-for-patients-with-type-2-diabetes-mellitus.pdf
June 03, 2010 - Complex Patients Require Complex
Treatment Decisions
Multiple Possible Adverse Outcomes
Which are … Multiple guidelines often apply
Modeling Outcomes in Diabetes
Cardiff Diabetes Model (Discrete Events … )
UKPDS Outcomes Model (Discrete Events)
UKPDS Risk Engine (Regression)
EAGLE (Monte Carlo)
CORE … Risk
Diminishing Returns
When there are many different ways to reduce the risk of a
particular adverse
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs023661-cutrona-final-report-2017.pdf
January 01, 2017 - drug events. … drug events. … drug events. … Adverse drug events were assessed
for a subset of alerts. … To
identify adverse drug events during an observation period of 1-45 days post hospital
discharge,
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digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/long-term-care/computerized-physician-order-0
informing prescribing decisions, reducing the frequency of prescribing and monitoring errors, and reducing adverse
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018649-levick-final-report-2014.pdf
January 01, 2014 - pregnancy outcomes and
birth events. … birth events that typically occur during or immediately after delivery. … After identifying the
adverse events through chart review, we weighted them in accordance with their … birth events. … In particular, we estimate 37% reduction in the severity of adverse birth events, such as
harm
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digital.ahrq.gov/sites/default/files/docs/publication/guide-to-reducing-unintended-consequences-of-electronic-health-records.pdf
August 01, 2011 - Figure 4.1 Timeline of events that led to the heparin overdose in the ED
more specific questions to … Figure 4.1 presents a timeline of events that led up to the adverse event
that resulted from the error … The timeline makes it possible to construct the chain of events that led to the adverse event. … A structured method used to analyze serious adverse events. … events).
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digital.ahrq.gov/sites/default/files/docs/implementation/Young%202-II.ppt
December 12, 2012 - difference
Identify priority areas for intervention
Existing Measures
Limited to counting events … :
Frequency by patient
Total number of events
Events per patient
May or may not include counts by subcategories … Cannot evaluate severity using standard schema due to lack of required data (e.g., assessment of adverse
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digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/return-investment/return-investment
January 01, 1993 - cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse
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digital.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-record/annual-summary/2011
January 01, 2011 - HIV RNA, depression, anxiety, and quality of life; 4) safety, i.e. documentation of drug allergies, adverse … events, and medication reconciliation; and 5) utilization, including office visits.
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digital.ahrq.gov/ahrq-funded-projects/decision-support-improve-dental-care-medically-compromised-patients/annual-summary/2012
January 01, 2012 - (Upcoming)
Determine the impact of the active versus passive CDS interventions upon reducing adverse … events and emergency care compared to the control group.
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digital.ahrq.gov/sites/default/files/docs/page/2006Wang_051611comp.pdf
January 01, 2006 - School of Medicine - Department of Emergency Medicine
“How Can a Life-Saving Intervention
Lead to Adverse … “Is Poor Outcome Due to
Adverse Events and Errors?”
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digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/financial-analysis-projects
January 01, 2002 - Quality of Care and Patient Safety Outcome: Assumed 28% reduction in adverse drug events (ADEs).
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/eslami-s-et-al-2007
January 01, 2007 - The effect was not significant on the number of adverse drug events.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023696-bates-final-report-2019.pdf
January 01, 2019 - patient safety problems in hospitals
suggest that medication safety remains the leading category of adverse … events.3,4 Other studies of … Fatal orders
are ones that have killed patients in the past or caused a severe adverse drug event; … “Global trigger tool” shows that adverse events in
hospitals may be ten times greater than previously … High Rates of Adverse Drug
Events in a Highly Computerized Hospital.
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digital.ahrq.gov/sites/default/files/docs/clinical-workflow-slides-072915.pdf
July 29, 2015 - Opportunistic decision making
• Potential impact of opportunistic decisions on care
► Potential risk of adverse … events
► Decreased quality of care/increased length of stay
► Decreased satisfaction
Opportunistic … • Its impact on patient care is reflected by a
decrease of productivity and increase of
potential adverse … events
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digital.ahrq.gov/sites/default/files/docs/activity/randomized_control_trial_embedded_in_an_ehr_2010_pdf__2.pdf
January 01, 2010 - HIV RNA, depression, anxiety, and quality
of life; safety, such as documentation of drug allergies, adverse … events, and medication reconciliation;
and utilization, such as office visits.