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monahrq.ahrq.gov/news/blog/ahrqviews/addressing-historical-racism.html
April 01, 2021 - Studies
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AHRQ Views
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AHRQ News Now
Events … this section
News
Newsroom
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AHRQ Views
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Events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
May 01, 2017 - Patients on perinatal units can experience cardiopulmonary and metabolic events or deterioration that … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated. … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … Elements
Examples
Have a process in place to review severe maternal or neonatal morbidity and mortality events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2023.pdf
March 01, 2024 - able to use Measure Dx to guide their efforts to detect, analyze, and
learn from diagnostic safety events … IHS • Existing Activities Regarding Diagnostic Safety
o Voluntary adverse event report via I-STAR. … optimize this effort, as they are focused on root cause analysis
standardization to help in identifying events
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monahrq.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
April 01, 2021 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … outpatient monitoring for high-risk conditions, and (c) enhanced medication comprehension to reduce adverse … drug events.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
December 01, 2022 - Standard forms for the data collection and model procedures for the uniform
registration of events are … , such as
medication prescriptions and laboratory test results that are relevant to patient safety events … Measures and modules included in calculation of adverse event rates
Measure Module
One or more adverse … outcomes Birth - Maternal
Adverse event associated with hypoglycemic agent Medication
Adverse event … events Pressure Ulcer
Venous thromboembolism/pulmonary embolism (VTE/PE)
not related to procedure
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
December 01, 2023 - Standard forms for the data collection and model procedures for the uniform
registration of the events … , such as medication
prescriptions and laboratory test results that are relevant to patient safety events … Measures and modules included in calculation of adverse event rates
Measure Module
One or more adverse … outcomes Birth - Maternal
Adverse event associated with hypoglycemic agent Medication
Adverse event … events Pressure Ulcer
Venous thromboembolism/pulmonary embolism
(VTE/PE) not related to procedure
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monahrq.ahrq.gov/pcor/library-of-resources/index.html
April 01, 2021 - Studies
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Events … database , which contains information on study participants and a summary of study outcomes, including adverse … events.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - 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. … Future events are simply described. … Conventional Responses can include…
■ Describe Mary’s current condition and the events that led up to
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monahrq.ahrq.gov/pcor/strategic-framework/mission.html
July 01, 2023 - Studies
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Events
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monahrq.ahrq.gov/news/newsroom/case-studies/index.html?page=1
September 01, 2021 - Studies
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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
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monahrq.ahrq.gov/teamstepps/instructor/reference/teamattitudesmanual.html
April 01, 2017 - Studies
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Events … safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … Adverse events may be reduced by maintaining an information exchange with patients and their families
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monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
January 01, 2021 - Care 1
INTRODUCTION
High rates of readmissions are a major patient safety problem associated with adverse … events
such as prescribing errors and misdiagnoses of conditions in the hospital and ambulatory care … As the evidence base for reducing adverse events and readmission from the primary care setting
grows … role of the primary care team
in improving quality and safety for patients and reducing postdischarge adverse … events and
potentially preventable readmissions.
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monahrq.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6g-rapid-referral.html
April 01, 2023 - Studies
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AHRQ Views
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AHRQ News Now
Events … Guidance
Supplemental Items
Using CAHPS Surveys
CAHPS Databases
Webcasts & Recent Events … possibility of delays in care, which generates greater anxiety and contributes to a greater risk of adverse
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monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-asa-measure.pptx
April 01, 2016 - Measure Exceptions
Adverse effect, allergy, or intolerance to Aspirin and Plavix (Clopidogrel). … Ischemic Vascular Disease
Secondary prevention is where the evidence is the best
Reduces risk of vascular events
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monahrq.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2013 - Studies
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AHRQ Views
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse
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monahrq.ahrq.gov/news/newsroom/case-studies/index.html?page=7
January 01, 2016 - Studies
Blog
AHRQ Views
Newsletter
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
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monahrq.ahrq.gov/news/newsroom/case-studies/index.html?page=6
August 01, 2016 - Studies
Blog
AHRQ Views
Newsletter
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
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - abdominal surgeries, and is
associated with significant risk of mortality between 14% and 50%.1 Other adverse … events
include prolonged length of stay, subsequent surgeries and incisional herniation.2,3
• Proper
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - foreign objects avoidable.1
• Retained foreign objects represent a serious and significant patient adverse … Chasing zero events of harm: an urgent call to expand safety culture work and
customer engagement.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
May 01, 2017 - L&D Unit Safety
30
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. … Factors to consider:
Unit and malpractice claims data suggesting adverse events or near misses related