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healthcare411.ahrq.gov/programs/index.html?page=2
April 28, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … 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.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
April 02, 2020 - Detecting adverse events for patient safety research: a
review of current methodologies. … Measuring errors and adverse events in health care. … 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.
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healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures. … Simulations—that an L&D unit can use to teach team members how to apply CUSP to prevent obstetrical adverse … events.
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healthcare411.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Older adults have a high prevalence of chronic pain and are especially vulnerable to adverse events from … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/848.html
January 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … published in the journal Cancer found that 10 percent of children with leukemia or lymphoma experienced adverse … drug events due to outpatient medication errors. … systematic review, from AHRQ’s Effective Health Care Program, also found PBI had significantly fewer acute adverse … events than WBI, though there was no apparent difference in late adverse events.
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healthcare411.ahrq.gov/research/findings/evidence-based-reports/search.html
May 01, 2024 - Affiliation: RTI International—University of North Carolina at Chapel Hill Report Status: Final
Adverse … Status: Final
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … Drug Events Date: February 2024
Report Type: Rapid Evidence Product Affiliation: Southern California … International—University of North Carolina at Chapel Hill Report Status: Final
Reducing Adverse … Drug Events Related to Anticoagulant Use in Adults Date: January 2024
Report Type: Rapid Evidence
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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … responsible for item or Action Plan
Reporting Culture
Are policies in place to support reporting adverse … clinical events? … Does your facility review patient safety events openly and share lessons learned? … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place?
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-may2015.pptx
January 01, 2015 - Safety in the US: Ongoing Problems
Institute of Medicine, 1999
44,000-98,000 deaths per year due to adverse … events
Office of the Inspector General, 2010
180,000 deaths per year due to adverse events
North Carolina … 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
I-PASS
Slide ‹#›
Results: Medical Error and Preventable Adverse … JAMA 2013; 310: 2262-2270
Pre-RHB Post-RHB p-value
Medical Errors 33.8 18.3 <0.001
Preventable Adverse … implementation associated with:
Primary outcome
A significant reduction in overall error rates and preventable adverse
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - individual staff skills with respect to EFM interpretation may not be enough to reduce perinatal safety events … Slide 12
SAY:
A unit can decide its approach to debriefing events based on seriousness of event, expertise … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … events. … events related to EFM use
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healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … Slide 13: 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. … Disclosing any unintended outcomes using unit policy for adverse events. … Past adverse events related to EFM use.
Synergy with related or similar initiatives.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
February 21, 2023 - Cancer-Free
Survival
Outcomes Similar at 5 and 10 Years
Whole Breast
Irradiation (WBI) Acute
Adverse … Events Were
Significantly
Fewer With
PBI
Compared
With WBI
Partial Breast
Irradiation (PBI)
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healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - Do they believe the organization is aware of all the patient harm events? … Have they heard of events that should have been reported but were not reported? … Other methods of reporting CANDOR events may include in-person reporting. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
October 01, 2017 - events? … events
Through a
noninvasive
interface after
HMV, BPAP, or
CPAP
Patients with
chronic respiratory … (KQ 5)
Adverse
Events
using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … events
Timing
• At least 1 month of treatment
Setting
• Home
• Assisted living residence
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - regarding the definition of true postoperative respiratory failure,
it still remains an important patient adverse … at increased risk for postoperative respiratory failure
to better prepare clinicians to anticipate adverse … events postoperatively, as well as improve
allocation of resources after surgery.5
• Some risk factors … Decreased central nervous system input (head injury, ingestion of central nervous system
depressant, adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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healthcare411.ahrq.gov/hai/universal-icu-decolonization/index.html
September 01, 2013 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Safety and Adverse Events
The REDUCE MRSA Trial (Randomized Evaluation of Decolonization … Safety and Adverse Events
Authors
University of California Irvine
Susan Huang, MD, MPH
Adrijana
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
October 01, 2015 - • AHRQ QIs are indicators of hospital quality and
adverse events that patients may experience as … • Pediatric Quality Indicators (PDIs) reflect quality of care
inside hospitals and adverse events … • The PSIs are a set of 18 hospital-level indicators of
safety-related adverse events following operations … and Safety
• The PDIs are a set of 16 indicators that reflect quality
of care inside hospitals and adverse … • PDIs measure events likely preventable through
changes at the system or provider level.
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healthcare411.ahrq.gov/research/findings/studies/index.html?page=484
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention
Braithwaite S , Friedman … events. … events. … Keywords: Adverse Events, Hospitals, Medical Errors, Patient Safety, Quality Indicators (QIs)
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - events. … drug events. … events. … These adverse events are relevant because obstetric and perinatal-related claims
are among the most … An ACEx2 program differs from other disclosure and offer models
“because it focuses on adverse events
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/870.html
June 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Researchers found that the interventions could prevent more than 3,100 ASCVD events over 10 years and … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Associated With Financial Distress
An analysis of more than 132,000 individuals’ credit reports showed adverse … Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
May 01, 2017 - 3
SAY:
Further, EFM interpretation and management
is a common issue in litigation involving
adverse … individual staff skills with
respect to EFM interpretation may not be
enough to reduce perinatal safety events … Perinatal Care Electronic Fetal Monitoring 8
SAY:
A unit can decide its approach to debriefing
events … events. … • Past adverse events related to EFM use.
• Synergy with related or similar initiatives
(e.g., initiatives