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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
July 23, 2010 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … As noted above, one study found that more than 70 percent of adverse events are caused by breakdowns … infections, and air embolism, all of which are on CMS’s list of hospital-acquired complications “never events … successful transfer of information between nurses going off duty and nurses coming on duty to prevent adverse … events and medical errors.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pdf
November 19, 2008 - The Story of Willie Ramirez
SAY:
To illustrate why LEP patients are at risk of patient safety events … Language proficiency and
adverse events in U.S. hospitals: a pilot study. … inspired by the
2006 book by John Kotter, Our Iceberg Is Melting: Changing and
Succeeding Under Adverse … Our iceberg is melting: changing
and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors
found in malpractice cases and sentinel events
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/825.html
August 01, 2022 - Studies
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AHRQ Views
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AHRQ News Now
Events … section
News
Newsroom
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Events … Articles featured this week include:
Trends in adverse event rates in hospitalized patients, 2010-2019
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/880.html
September 01, 2023 - Studies
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Events … section
News
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Events … of implementation factors related to addressing social determinants to reduce racial disparities in adverse
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healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
July 01, 2023 - Studies
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AHRQ Views
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AHRQ News Now
Events … Elements
Slide 31: Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse … events. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … Factors to consider:
Unit and malpractice claims data suggesting adverse events or near misses related
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healthcare411.ahrq.gov/teamstepps-program/curriculum/intro/overview.html
July 01, 2023 - Studies
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Events
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healthcare411.ahrq.gov/teamstepps/readiness/index.html
August 01, 2015 - Studies
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Events … Objective information can originate from a variety of sources, including adverse event and near-miss
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healthcare411.ahrq.gov/news/blog/ahrqviews/uneven-impact-covid19.html
December 01, 2021 - Studies
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Events … this section
News
Newsroom
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Events
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healthcare411.ahrq.gov/patient-safety/resources/learning-lab/index.html
February 01, 2024 - drug events. … Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general … drug events. … patient safety events. … events, and improve efficiency for ED healthcare providers.
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healthcare411.ahrq.gov/news/blog/ahrqviews/addressing-historical-racism.html
April 01, 2021 - Studies
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Events … this section
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Events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
May 01, 2017 - Patients on perinatal units can experience cardiopulmonary and metabolic events or deterioration that … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated. … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … Elements
Examples
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/dx-safety-workgroup-meeting-notes-nov2023.pdf
March 01, 2024 - able to use Measure Dx to guide their efforts to detect, analyze, and
learn from diagnostic safety events … IHS • Existing Activities Regarding Diagnostic Safety
o Voluntary adverse event report via I-STAR. … optimize this effort, as they are focused on root cause analysis
standardization to help in identifying events
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healthcare411.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
April 01, 2021 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … outpatient monitoring for high-risk conditions, and (c) enhanced medication comprehension to reduce adverse … drug events.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
December 01, 2022 - Standard forms for the data collection and model procedures for the uniform
registration of events are … , such as
medication prescriptions and laboratory test results that are relevant to patient safety events … Measures and modules included in calculation of adverse event rates
Measure Module
One or more adverse … outcomes Birth - Maternal
Adverse event associated with hypoglycemic agent Medication
Adverse event … events Pressure Ulcer
Venous thromboembolism/pulmonary embolism (VTE/PE)
not related to procedure
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healthcare411.ahrq.gov/sites/default/files/2024-01/joseph3-report.pdf
January 01, 2024 - Scope
The incidence of adverse events, such as surgical site infections and surgical errors, is an
immense … Previous attempts to reduce
adverse events in the OR have focused on enhancing skills and training for … Research in complex settings suggests that adverse events are
often caused by a combination of active
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
December 01, 2023 - Standard forms for the data collection and model procedures for the uniform
registration of the events … , such as medication
prescriptions and laboratory test results that are relevant to patient safety events … Measures and modules included in calculation of adverse event rates
Measure Module
One or more adverse … outcomes Birth - Maternal
Adverse event associated with hypoglycemic agent Medication
Adverse event … events Pressure Ulcer
Venous thromboembolism/pulmonary embolism
(VTE/PE) not related to procedure
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healthcare411.ahrq.gov/pcor/library-of-resources/index.html
April 01, 2021 - Studies
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Events … database , which contains information on study participants and a summary of study outcomes, including adverse … events.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - communicators who participate in conversations
with patients, families, and caregivers following an adverse … demonstrate all of the skills and competencies should be involved in delivering communication about adverse … events to patients, families, and caregivers. … Future events are simply described. … Conventional Responses can include…
■ Describe Mary’s current condition and the events that led up to
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healthcare411.ahrq.gov/pcor/strategic-framework/mission.html
July 01, 2023 - Studies
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Events
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healthcare411.ahrq.gov/news/newsroom/case-studies/index.html?page=1
September 01, 2021 - 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