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  1. monahrq.ahrq.gov/teamstepps-program/resources/additional/sbar.html
    July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … how this technique, one tool in the TeamSTEPPS training program, can improve communication, reduce adverseevents, and improve care quality.
  2. monahrq.ahrq.gov/news/newsletters/e-newsletter/872.html
    July 01, 2023 - process can enrich clinicians’ understanding of patient and family experience and reduce harms following adverse … diagnostic events. … It describes the most effective ways of eliciting fulsome accounts about diagnosis-related events and … emergency departments to provide nonemergency care to residents, potentially placing residents at risk of adverseevents and generating wasteful Medicare spending.
  3. monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Her team found that 10 percent of children with leukemia or lymphoma experienced adverse drug events
  4. monahrq.ahrq.gov/news/newsroom/case-studies/index.html?page=4
    June 01, 2017 - 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 … Study Identifier: 2017-10 AHRQ Product(s): Comprehensive Unit-based Safety Program (CUSP) Topic(s): Adverse … Drug Events (ADE), Healthcare Costs, Healthcare-Associated Infections (HAIs), Hospital Readmissions, … Safety Program (CUSP), Patient Safety Organization (PSO), Re-Engineered Discharge (RED) Topic(s): Adverse
  5. monahrq.ahrq.gov/patient-safety/about/areas.html
    February 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Learn about Patient Safety Patient Safety and Quality Areas Patient Safety News and Events … Team Training Falls Pressure Ulcers Diagnostic Safety Blood Clot Prevention and Treatment Adverse … Drug Events AHRQ Quality Indicators (QIs) Page last reviewed February
  6. monahrq.ahrq.gov/news/newsletters/e-newsletter/856.html
    March 01, 2023 - section News Newsroom Blog Newsletter AHRQ News Now Events … Articles featured this week include: Automated capture of intraoperative adverse events using artificial … Near-miss events detected using the emergency department trigger tool . … Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated … events in critically ill children.
  7. monahrq.ahrq.gov/news/newsletters/e-newsletter/828.html
    August 01, 2022 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … and introduces Measure Dx , a new evidence-based tool that helps users identify diagnostic safety events … Drug-drug interactions are responsible for up to 14 percent of adverse drug reactions in hospitalized … Articles featured this week include: Quality measures for patients at risk of adverse outcomes in the
  8. monahrq.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
    January 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Assessment Form  (DOCX, 330 KB) Implementation Guide  (PDF, 402 KB) Learning From Antibiotic–Associated AdverseEvents Form (DOCX, 227 KB) Gap Analysis Tool  (DOCX, 382 KB) The Four Moments of Antibiotic Decision
  9. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
    December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … 1 2 3 4 5 SECTION D: Frequency of Events Reported In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an adverse event happens ....... … 1 2 3 4 5 SECTION G: Number of Events Reported In the past 12 months, how many event reports
  10. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
    April 01, 2011 - ------------------------------------------------------------------- 9 How to prevent adverse events … one study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge How does the IDEAL Discharge Planning strategy improve
  11. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
    April 01, 2011 - 9 How to prevent adverse events after discharge 11 How does the IDEAL Discharge Planning strategy improve … study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … How to prevent adverse events after discharge Many of the challenges described above can be attributed … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital.
  12. monahrq.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
    December 01, 2017 - mortality for pediatric surgical procedures Rates of potentially avoidable complications and adverse … for Selected Procedures) IQI 91 (Mortality for Selected Conditions) PSI 90 (Patient Safety and AdverseEvents Composite) PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … References Slide 48 Sample Best Practices Pressure ulcers represent an important patient adverse
  13. monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-roster-2023dec.pdf
    December 21, 2023 - Medical Officer Name Department/Agency Title Michael Lee, Pharm.D., BCPS, CAPT, USPHS IHS IHS AdverseEvents Coordinator, IHS Office of Quality, Division of Quality Assurance and Patient Safety Phillippe
  14. monahrq.ahrq.gov/news/newsletters/e-newsletter/900.html
    February 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Reducing Adverse Events Related to Anticoagulants . Implicit Bias Training . Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .
  15. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - multidisciplinary review is required to identify system processes that may result in failures in care, adverseevents, and mortality … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … Summary data of sentinel events reviewed by The Joint Commission.
  16. monahrq.ahrq.gov/news/newsletters/e-newsletter/875.html
    August 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis . … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality
  17. monahrq.ahrq.gov/talkingquality/translate/compare/choose/standard.html
    January 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … The Standard for “Never Events” There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”
  18. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
    June 09, 2016 - ” · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … questions when something does not seem right 1 2 3 4 5 9 SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported? a. … Hospital management seems interested in patient safety only after an adverse event happens 1 2 3
  19. monahrq.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
    November 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now EventsAdverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual support … Staff members are concerned that we could have an adverse event due to breakdowns in team skills.   … prophylactic use of beta-blockers to prevent intra-operative myocardial ischemia]; decreased rates of adverseevents or near misses)   Who will be involved in the change?
  20. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
    May 01, 2017 - Admin. 10 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse events … inductions outside of policy-defined indications severe maternal or neonatal morbidity and mortality events … Admin. 23 Key Safety Elements: Learn From Defects Debrief near misses and adverse events related … magnesium sulfate outside of defined indications severe maternal or neonatal morbidity and mortality events … Consider these factors: Unit data suggesting adverse events or near misses related to oxytocin, magnesium

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