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monahrq.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Older adults have a high prevalence of chronic pain and are especially vulnerable to adverse events from … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
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monahrq.ahrq.gov/research/findings/studies/index.html
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe … Adverse tracheal intubation events in critically ill underweight and obese children: retrospective study … Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of … The study did not find significant differences in adverse events. AHRQ-funded; HS024511.
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monahrq.ahrq.gov/news/newsletters/e-newsletter/848.html
January 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … published in the journal Cancer found that 10 percent of children with leukemia or lymphoma experienced adverse … drug events due to outpatient medication errors. … systematic review, from AHRQ’s Effective Health Care Program, also found PBI had significantly fewer acute adverse … events than WBI, though there was no apparent difference in late adverse events.
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monahrq.ahrq.gov/research/findings/evidence-based-reports/search.html
April 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Affiliation: RTI International—University of North Carolina at Chapel Hill Report Status: Final
Adverse … Status: Final
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … International—University of North Carolina at Chapel Hill Report Status: Final
Reducing Adverse … Drug Events Related to Anticoagulant Use in Adults Date: January 2024
Report Type: Rapid Evidence
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … responsible for item or Action Plan
Reporting Culture
Are policies in place to support reporting adverse … clinical events? … Does your facility review patient safety events openly and share lessons learned? … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place?
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - individual staff skills with respect to EFM interpretation may not be enough to reduce perinatal safety events … Slide 12
SAY:
A unit can decide its approach to debriefing events based on seriousness of event, expertise … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … events. … events related to EFM use
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monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … Slide 13: 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. … Disclosing any unintended outcomes using unit policy for adverse events. … Past adverse events related to EFM use.
Synergy with related or similar initiatives.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
February 21, 2023 - Cancer-Free
Survival
Outcomes Similar at 5 and 10 Years
Whole Breast
Irradiation (WBI) Acute
Adverse … Events Were
Significantly
Fewer With
PBI
Compared
With WBI
Partial Breast
Irradiation (PBI)
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - regarding the definition of true postoperative respiratory failure,
it still remains an important patient adverse … at increased risk for postoperative respiratory failure
to better prepare clinicians to anticipate adverse … events postoperatively, as well as improve
allocation of resources after surgery.5
• Some risk factors … Decreased central nervous system input (head injury, ingestion of central nervous system
depressant, adverse … Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
October 01, 2017 - events? … events
Through a
noninvasive
interface after
HMV, BPAP, or
CPAP
Patients with
chronic respiratory … (KQ 5)
Adverse
Events
using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … events
Timing
• At least 1 month of treatment
Setting
• Home
• Assisted living residence
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monahrq.ahrq.gov/hai/universal-icu-decolonization/index.html
September 01, 2013 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Safety and Adverse Events
The REDUCE MRSA Trial (Randomized Evaluation of Decolonization … Safety and Adverse Events
Authors
University of California Irvine
Susan Huang, MD, MPH
Adrijana
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - Do they believe the organization is aware of all the patient harm events? … Have they heard of events that should have been reported but were not reported? … Other methods of reporting CANDOR events may include in-person reporting. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.
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monahrq.ahrq.gov/research/findings/studies/index.html?page=484
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention
Braithwaite S , Friedman … events. … events. … Keywords: Adverse Events, Hospitals, Medical Errors, Patient Safety, Quality Indicators (QIs)
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - events. … drug events. … events. … These adverse events are relevant because obstetric and perinatal-related claims
are among the most … An ACEx2 program differs from other disclosure and offer models
“because it focuses on adverse events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
May 01, 2017 - 3
SAY:
Further, EFM interpretation and management
is a common issue in litigation involving
adverse … individual staff skills with
respect to EFM interpretation may not be
enough to reduce perinatal safety events … Perinatal Care Electronic Fetal Monitoring 8
SAY:
A unit can decide its approach to debriefing
events … events. … • Past adverse events related to EFM use.
• Synergy with related or similar initiatives
(e.g., initiatives
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monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-slides.html
July 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Slide 14: Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse events … Have a process in place to review serious maternal or neonatal adverse outcomes. … Consider these factors:
Unit data suggesting adverse events or near misses that may have been minimized … Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to
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monahrq.ahrq.gov/news/newsletters/e-newsletter/870.html
June 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Researchers found that the interventions could prevent more than 3,100 ASCVD events over 10 years and … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Associated With Financial Distress
An analysis of more than 132,000 individuals’ credit reports showed adverse … Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
May 01, 2017 - Professional Liability
EFM interpretation and management are a common issue in litigation involving adverse … events, and the contribution of EFM use, EFM interpretation, and communication of EFM findings. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events
17
AHRQ Safety Program for Perinatal Care
Electronic
Fetal Monitoring
17
Unit Next Steps … Past adverse events related to EFM use
Synergy with related or similar initiatives
Interest and enthusiasm
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monahrq.ahrq.gov/research/findings/studies/index.html?page=1
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(736)
Alcohol Use
(61)
Ambulatory Care and Surgery … events. … events were rare. … Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse events. … Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse
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monahrq.ahrq.gov/research/findings/studies/index.html?page=2
January 01, 2024 - Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery … events. … events were rare. … Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse events. … Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse