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monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
November 03, 2022 - of our resource – Measure Dx: A
Resource To Identify, Analyze, and Learn From Diagnostic Safety
Events … IHS • Enhanced Adverse Event Reporting Capabilities
o IHS Safety Tracking and Response (I-STAR) is deployed … Current projects include working on overdue events
and development of standardized reporting at the
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monahrq.ahrq.gov/news/newsletters/e-newsletter/890.html
November 01, 2023 - Studies
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Events … antibiotics within 48 hours of presentation and in 13 percent of hospitalizations patients experienced an adverse … time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse … events were rare.
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monahrq.ahrq.gov/news/newsletters/e-newsletter/907.html
April 01, 2024 - Studies
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Events … section
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Events … of team strategies and tools to improve performance and approaches to team-based error disclosure on adverse … events. … Articles featured this week include:
Transfusion-related errors and associated adverse reactions and
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monahrq.ahrq.gov/patient-safety/reports/national-action-plans.html
February 01, 2018 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies
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monahrq.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - Studies
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Events … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality … Risk factors for opioid-related adverse drug events among older adults after hospitalization for major
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monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - ”
• “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5 9
5
SECTION D: Reporting Patient Safety Events
Think about your unit/work … 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 .......
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monahrq.ahrq.gov/news/newsletters/e-newsletter/874.html
August 01, 2023 - Studies
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Events … available to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures. … Articles featured this week include:
Anticoagulation-associated adverse drug events in hospitalized
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … 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.
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - Studies
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About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … management
Disruptive behavior and/or code of conduct
Investigation of occurrences (i.e., sentinel events … ___
Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse … or "harm" events
___
___
Organizational safety and/or quality plan
FMEAs or other
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monahrq.ahrq.gov/teamstepps/lep/handouts/lepevidencesum.html
December 01, 2012 - Studies
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Events … TeamSTEPPS® Enhancing Safety for Patients With Limited English Proficiency Module
Patient safety events … receive professional interpretation services. 3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
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monahrq.ahrq.gov/research/findings/final-reports/index.html?page=2
September 01, 2018 - Studies
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Events … Review Process of High-Risk Drugs Using a Patient-Centered, Telemedicine-Based Approach to Prevent Adverse … Drug Events in the Nursing Home ( application/pdf 471675 ) Principal Investigators: Kane-Gill, … 023464 Topic(s): Medication Safety, Nursing Homes Publication Date: September 2018
Reducing Adverse … Drug Events from Anticoagulants, Diabetes Agents and Opioids in Primary Care ( application/pdf 470629
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monahrq.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
January 01, 2024 - events and achieved a 60% reduction in surgical site infections in designated cardiac,
neurosurgery … , and orthopedic procedures35 and a 34.5% reduction in overall adverse drug events. … Occurrence of adverse, often preventable, events in community
hospitals involving nephrotoxic drugs or … A trigger tool to identify adverse events in the intensive
care unit. … Incidence of adverse drug events and potential adverse drug events.
Implications for prevention.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - learning from defects for oxytocin administration include—
Debriefing and analyzing near misses and adverse … Having a process in place to review severe maternal or neonatal morbidity and mortality events. … key safety elements of learning from defects are the same as for oxytocin:
Debriefing near misses and adverse … events related to magnesium sulfate use. … Consider these factors:
· Unit data suggesting adverse events or near misses related to oxytocin, magnesium
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monahrq.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Studies
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Events … hospitals and nursing homes (including skilled nursing facilities) to collect data for all types of adverse … events, near misses, and unsafe conditions. … Research suggests that adverse events affect patients with limited English proficiency more frequently … If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications
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monahrq.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy3/index.html
December 01, 2017 - Studies
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Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors.
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monahrq.ahrq.gov/patient-safety/reports/candor-demo-program/candor/demo-program/index.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … These projects sought to improve patient safety by measuring safety problems, characterizing adverse … events, and conducting clinical safety interventions.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - for engaging patients and families in discharge planning
Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented
or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse … of these could have been prevented
or ameliorated.1 Common post-discharge complications
include adverse … drug events, hospital-acquired infections,
and procedural complications.1 Many of these
complications … The
incidence and severity of adverse events affecting
patients after discharge from the hospital.
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monahrq.ahrq.gov/topics/index.html?page=1
January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
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monahrq.ahrq.gov/es/topics/index.html?page=1
January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.