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monahrq.ahrq.gov/es/programs/index.html?page=3
March 31, 2024 - 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.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
August 07, 2012 - Poor communication among staff is a root cause of many patient adverse and sentinel events.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule10.pptx
January 01, 2004 - Slide 19)
Measure Level IV - Results
Provide information on potential in-hospital complications and adverse … events
Can help identify potential adverse events that might need further study
Include indicators … The PSIs are a set of measures that provide information about potential in-hospital complications and adverse … events following surgeries, other hospital or care procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse events that might require further study
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanage_quickstartbrochure.pdf
December 15, 2016 - medication reconciliation and
medication management are well documented.2-5 One study
found that adverse … drug events result in as many as 4.5 million
ambulatory visits (office and emergency department) each … It will also help you identify patient behaviors
that may be putting them at risk for an adverse drug … with patients and families to prepare the medication list and
identify patients at risk for safety events … Adverse drug events
in U.S. adult ambulatory medical care.
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monahrq.ahrq.gov/teamstepps/webinars/previous-webinars-2013.html
August 01, 2017 - Studies
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AHRQ Views
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AHRQ News Now
Events … Identify common causes of adverse events for LEP and culturally diverse patients. … strategies for improving detection of medical errors and preventing high-risk scenarios from becoming safety events … Provide an approach to preventing safety events through the use of TeamSTEPPS tools.
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monahrq.ahrq.gov/research/findings/studies/index.html?page=480
January 01, 2024 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events … 1279)
2015
(1430)
2014
(662)
2013
(195)
Topics
Access to Care
(417)
Adverse … Drug Events (ADE)
(321)
Adverse Events
(736)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Opioids, Medication, Substance Abuse, Screening, Adverse Drug Events (ADE), Adverse Events
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monahrq.ahrq.gov/research/findings/studies/index.html?page=481
January 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … 1279)
2015
(1430)
2014
(662)
2013
(195)
Topics
Access to Care
(417)
Adverse … Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Opioids, Medication, Substance Abuse, Screening, Adverse Drug Events (ADE), Adverse Events
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monahrq.ahrq.gov/cpi/about/otherwebsites/PBRN/pbrn.html
September 01, 2018 - Studies
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AHRQ Views
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AHRQ News Now
Events … Field testing of a new ambulatory care electronic Medication Errors and Adverse Drug Events Reporting
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monahrq.ahrq.gov/tools/index.html?page=3
September 01, 2012 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events … and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse … events resulting from poor communication and system failures.
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monahrq.ahrq.gov/hai/universal-icu-decolonization/universal-icu-overvw.html
September 01, 2013 - Studies
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Events … Safety and Adverse Events
Introduction to the Protocol
The Universal ICU Decolonization
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monahrq.ahrq.gov/teamstepps/instructor/reference/teamattitude.html
April 01, 2017 - Studies
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Events … Adverse events may be reduced by maintaining an information exchange with patients and their families
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monahrq.ahrq.gov/research/publications/search.html?page=17
March 01, 2010 - Studies
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AHRQ News Now
Events … patient safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse … events from occurring in your hospital.
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monahrq.ahrq.gov/es/tools/index.html?page=3
September 01, 2012 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events … and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse … events resulting from poor communication and system failures.
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monahrq.ahrq.gov/news/newsletters/e-newsletter/886.html
October 01, 2023 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Falls are one of the most frequently reported patient safety events in the NPSD, second only to medication … or other substance events. … Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive
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monahrq.ahrq.gov/news/newsroom/case-studies/index.html
February 01, 2024 - Studies
Blog
AHRQ Views
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AHRQ News Now
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 … Impact Case Study Identifier: 2023-01 AHRQ Product(s): SHARE Approach Topic(s): Access to Care, Adverse … Drug Events (ADE), Care Coordination, Chronic Conditions, Clinician-Patient Communication, Diabetes,
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monahrq.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Studies
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AHRQ Views
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AHRQ News Now
Events … Or a patient having wisdom teeth removed may have a strong adverse reaction to the sedation and require
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-sept2013.pptx
January 01, 2013 - TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Analysis of sentinel events … failure cited as a primary contributing factor in nearly 80 % of over 6,000 root cause analyses of adverse … events and close calls.
17
(Cost) Benefits of TeamSTEPPS
Decreased malpractice claims
Decreased … insurance premiums
Decreased litigation
Reduced rate of adverse drug events (from 30 to 18 per 1,000 … TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Upcoming TeamSTEPPS Events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
January 01, 2021 - The three measures that improved most reflect fewer adverse events
in nursing homes (two measures) and … fewer adverse drug events involving the blood thinner
heparin in hospital settings. … 2018, the incident rates of end stage renal disease due to diabetes
decreased 48% from 526 to 273.1 events … Alaska Native, Black, and White
populations, with respective incident rates of 273.1, 372.2, and 152.2 events … Hispanic communities
were still more than double the rates in non-Hispanic White communities (142.8
events
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monahrq.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
July 01, 2018 - Studies
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Events … How to communicate an adverse event to patients and family members.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - Defects (CUSP Element)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to shoulder dystocia … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events … Sample scenario:
· Shoulder dystocia
· Shoulder dystocia training can be effective at reducing adverse