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monahrq.ahrq.gov/teamstepps-program/resources/additional/sbar.html
July 01, 2023 - Studies
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AHRQ Views
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AHRQ News Now
Events … how this technique, one tool in the TeamSTEPPS training program, can improve communication, reduce adverse … events, and improve care quality.
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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 adverse … events and generating wasteful Medicare spending.
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monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Studies
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AHRQ Views
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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
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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
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monahrq.ahrq.gov/patient-safety/about/areas.html
February 01, 2018 - Studies
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AHRQ Views
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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
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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.
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monahrq.ahrq.gov/news/newsletters/e-newsletter/828.html
August 01, 2022 - Studies
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AHRQ Views
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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
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monahrq.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Studies
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AHRQ Views
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AHRQ News Now
Events … Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse … Events Form (DOCX, 227 KB)
Gap Analysis Tool (DOCX, 382 KB)
The Four Moments of Antibiotic Decision
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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
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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
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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.
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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 Adverse … Events 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
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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 Adverse … Events Coordinator, IHS Office of
Quality, Division of Quality Assurance and
Patient Safety
Phillippe
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monahrq.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
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AHRQ News Now
Events … section
News
Newsroom
Blog
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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 .
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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, adverse … events, 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.
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monahrq.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Studies
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AHRQ News Now
Events … section
News
Newsroom
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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
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monahrq.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
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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.”
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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
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monahrq.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Studies
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AHRQ Views
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AHRQ News Now
Events … Adverse 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 adverse … events or near misses)
Who will be involved in the change?
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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