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monahrq.ahrq.gov/data/infographics/hac-rates_2019.html
July 01, 2020 - Studies
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Events … (PDF, 11.1 MB)
Text Description: National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease. … Obstetric events: 3% decrease. Pressure ulcers: 6% increase. Surgical site infections: 8% increase.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8.
Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.
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monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - events and associated systemic and contextual factors. … Table of Contents
Adverse Drug Events (ADEs): General Medication Topics
ADEs: Harms Due to Anticoagulants … ADEs: Harms Due to Diabetic Agents
ADEs: Reducing Adverse Drug Events in Older Adults
ADEs: Harms … )
MHS III (2020)
Computer Adverse Drug Event Detection and Alerts
Summary of Evidence
(Not reviewed … Adverse Drug Events Related to Anticoagulants
Summary of Evidence
Update
(Not reviewed)
The
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monahrq.ahrq.gov/news/newsletters/e-newsletter/831.html
September 01, 2022 - section
News
Newsroom
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AHRQ News Now
Events … Potentially inappropriate medication administration is associated with adverse postoperative outcomes … Risk of metabolic and cardiovascular adverse events with abiraterone or enzalutamide among men with advanced … Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia … Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare
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monahrq.ahrq.gov/sops/about/patient-safety-culture.html
March 01, 2022 - Studies
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Events … 2
Hospitals with more positive SOPS scores had:
Lower rates of in-hospital complications or adverse … events as measured by AHRQ’s patient safety indicators (PSIs). 3
Patients who reported more positive … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - events. … If left
unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … events. … events increases after hospitalization. … events.
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monahrq.ahrq.gov/data/qualityindicators/index.html
November 01, 2020 - hospital level, the QIs are used to support internal quality improvement, monitoring, and assessment of adverse … events related to patient safety. … Patient Safety Indicators (PSIs) help hospitals assess the incidence of adverse events and in-hospital … More specifically, they focus on potential in-hospital complications and adverse events following surgeries … PDIs focus on potentially preventable complications and iatrogenic events for pediatric patients treated
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - 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/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
April 01, 2016 - ■ Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an
adverse … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize
■ Say you are sorry for the adverse event in a sincere manner early in the conversation.
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monahrq.ahrq.gov/antibiotic-use/acute-care/safety/index.html
June 01, 2021 - Studies
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Events … Use Commitment Poster (DOCX)
Antibiotic Time Out Tool (DOCX)
Identifying Antibiotic–Associated Adverse … Events Form (DOCX)
Learning From Antibiotic–Associated Adverse Events Form (DOCX)
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monahrq.ahrq.gov/hai/pfp/index.html
July 01, 2020 - Studies
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Events … Condition Rate ( PDF , 237 KB)
To improve how the Nation tracks its progress on reducing HACs and other adverse … events, AHRQ is developing the AHRQ Quality and Safety Review System . … This patient safety surveillance system will capture information about HACs and other adverse events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_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/news/newsletters/e-newsletter/852.html
February 01, 2023 - section
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Events … events on health systems. … events like multi-organ failure and heart problems, according to two AHRQ-funded studies published in … Food and Drug Administration’s Adverse Event Reporting System from January 2004 through June 2020. … It found a total of 787 reports that pointed to an adverse event from a colchicine drug interaction.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
March 11, 2022 - Indian Health
Service
• Enhanced Adverse Event Reporting Capabilities:
o Reporting of adverse events
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monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - care, where the complexity of the system and the fragility of the patients creates a greater risk for adverse … events. … a 2-year AHRQ grant in 2005 to evaluate an emergency medicine clinical pharmacist program to avoid adverse … drug events in emergency department (ED) patients. … Fairbanks evaluated over 10,000 ED cases for adverse events, and interviewed ED physicians and nurses
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monahrq.ahrq.gov/es/programs/index.html?page=2
March 31, 2024 - Studies
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Events … To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early.
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monahrq.ahrq.gov/programs/index.html?page=2
April 28, 2024 - Studies
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Events … To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early.
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monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - Studies
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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. … Simulations—that an L&D unit can use to teach team members how to apply CUSP to prevent obstetrical adverse … events.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
April 02, 2020 - Detecting adverse events for patient safety research: a
review of current methodologies. … Measuring errors and adverse events in health care. … Lessons
from a patient partnership intervention to prevent adverse drug events. … Computerized surveillance of adverse drug events
in hospital patients. … Adverse events during hospitalization: results of a patient survey.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
September 01, 2012 - Evidence shows that unaddressed language barriers put patients at high risk for adverse events. … The one hospital that
stratified their adverse event data by language found clusters of adverse events … Language pro�ciency and adverse events in U.S. hospitals: a pilot study. … Language proficiency and adverse events in U.S. hospitals: a pilot study. … • Emphasize potential differences between patient safety events and adverse events and distinguish