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healthcare411.ahrq.gov/es/tools/index.html?page=3
September 01, 2012 - Studies
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AHRQ News Now
Events … and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse … events resulting from poor communication and system failures.
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/886.html
October 01, 2023 - Studies
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Events … section
News
Newsroom
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Events … Falls are one of the most frequently reported patient safety events in the NPSD, second only to medication … or other substance events. … Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive
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healthcare411.ahrq.gov/news/newsroom/case-studies/index.html
February 01, 2024 - Studies
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Events … User Liaison Program (ULP)
(4)
WebM&M
(5)
Topics
Access to Care
(14)
Adverse … Drug Events (ADE)
(5)
Asthma
(2)
Behavioral Health
(16)
Blood Clots
(15)
Blood Thinners … Impact Case Study Identifier: 2023-01 AHRQ Product(s): SHARE Approach Topic(s): Access to Care, Adverse … Drug Events (ADE), Care Coordination, Chronic Conditions, Clinician-Patient Communication, Diabetes,
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healthcare411.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Studies
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Events … Or a patient having wisdom teeth removed may have a strong adverse reaction to the sedation and require
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-sept2013.pptx
January 01, 2013 - TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Analysis of sentinel events … failure cited as a primary contributing factor in nearly 80 % of over 6,000 root cause analyses of adverse … events and close calls.
17
(Cost) Benefits of TeamSTEPPS
Decreased malpractice claims
Decreased … insurance premiums
Decreased litigation
Reduced rate of adverse drug events (from 30 to 18 per 1,000 … TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Upcoming TeamSTEPPS Events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
January 01, 2021 - The three measures that improved most reflect fewer adverse events
in nursing homes (two measures) and … fewer adverse drug events involving the blood thinner
heparin in hospital settings. … 2018, the incident rates of end stage renal disease due to diabetes
decreased 48% from 526 to 273.1 events … Alaska Native, Black, and White
populations, with respective incident rates of 273.1, 372.2, and 152.2 events … Hispanic communities
were still more than double the rates in non-Hispanic White communities (142.8
events
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healthcare411.ahrq.gov/news/newsroom/case-studies/cquips0804.html
October 01, 2014 - Studies
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Events … AHRQ Social Media
AHRQ Stats
Impact Case Studies
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Events … The first is to share the results of surveys or data on adverse outcomes within a department.
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healthcare411.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
July 01, 2018 - Studies
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Events … How to communicate an adverse event to patients and family members.
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healthcare411.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 - Defects (CUSP Element)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to shoulder dystocia … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events … Sample scenario:
· Shoulder dystocia
· Shoulder dystocia training can be effective at reducing adverse
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healthcare411.ahrq.gov/teamstepps-program/resources/additional/labor.html
July 01, 2023 - Studies
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Events … techniques used in labor and delivery units can help improve communication and collaboration and reduce adverse
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/antibiotic-stewardship/abx-stewardship-part2.pptx
March 01, 2017 - about 40% of all prescriptions
Antibiotics can cause harm to residents
High risk of side effects and adverse … events
Major risk factor for Clostridium difficile infection
Driver of antibiotic resistance
Prescribers … of commitments and activities designed to “optimize the treatment of infections while reducing the adverse … events associated with antibiotic use.” … commitments and activities designed to optimize the treatment of infections while reducing the harmful events
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healthcare411.ahrq.gov/nursing-home/materials/vaccination/index.html
September 01, 2023 - Studies
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Events … the vaccine manufacturer, additional primary dose and booster shots, dates each shot is administered, adverse … the vaccine manufacturer, additional primary dose and booster shots, dates each shot is administered, adverse
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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-chui.html
March 01, 2022 - Studies
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Events … As a result, adverse drug events (ADEs) are frequent, costly, and potentially life-threatening,” according
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healthcare411.ahrq.gov/news/newsroom/press-releases/reduced-ltc-antibiotic-use.html
February 01, 2022 - Studies
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Events … AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
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Events … facilities also significantly reduced use of fluoroquinolones , a class of antibiotics known to cause adverse
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/847.html
January 01, 2023 - Studies
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Events … section
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Events … Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/829.html
August 01, 2022 - Studies
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Events … section
News
Newsroom
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AHRQ News Now
Events … Articles featured this week include:
Accuracy of pressure ulcer events in US nursing home ratings . … Emergency department adverse events detected using the emergency department trigger tool .
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events and the contribution of EFM use, EFM interpretation, and communication of EFM findings
· Unit … can decide its approach to debriefing events based on seriousness of event, expertise available, and … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
July 22, 2021 - IHS • Enhanced Adverse Event Reporting Capabilities: IHS Safety
Tracking and Response (I-STAR) system
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/898.html
January 01, 2024 - Studies
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Events … section
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Events … Hospital and associate professor of medicine at Harvard Medical School in Boston, is helping to reduce adverse … events during care transitions with digital health interventions that improve patient safety and outcomes … organizations and other groups can use these findings to improve how medication-related patient safety events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
January 01, 2022 - lags far behind other types of patient safety events. … Unlike the types of safety
events defined by existing Common Formats, diagnostic safety
events tend … events) and to email
written feedback within approximately 4 weeks. … The reliability of AHRQ
Common Format Harm Scales in rating patient safety events. … A human factors and survey
methodology-based design of a web-based adverse event reporting system
for