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pbrn.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
May 01, 2017 - This
principle calls for L&D unit teams to evaluate
their processes and learn from adverse
events, … Rapid
Response toolcall
• In addition, clinical teams can debrief
and analyze near misses and adverse … events, regardless of whether a rapid
response was activated. … Consider these
factors:
o Unit data suggesting adverse events or
near misses that may have been … • Regularly debrief after rapid response
events, and solicit ongoing feedback
from staff and patients
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/lepevidencesum.pdf
January 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more
severe … 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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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - Slide 11: Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse events … Severe maternal or neonatal morbidity and mortality events. … Slide 24: Key Safety Elements: Learn From Defects
Debrief near misses and adverse events related … Severe maternal or neonatal morbidity and mortality events. … Consider these factors:
Unit data suggesting adverse events or near misses related to oxytocin, magnesium
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pbrn.ahrq.gov/news/newsletters/e-newsletter/874.html
August 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
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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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
August 01, 2022 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … The comprehensive toolkit will allow hospitals to improve the management of patient safety events by … implementing processes that facilitate full disclosure of an adverse event, apology, and fair and rapid
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
August 07, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form.
II.
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pbrn.ahrq.gov/news/newsletters/e-newsletter/index.html
April 30, 2024 - Results
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Improvement and Bolster Survey Scores
February 6, 2024
Heart Failure Patients’ Risk of Adverse … Events Higher in Poor-Performing Hospitals
January 30, 2024
New Tool Helps Manage Opioid
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pbrn.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - hospitals and nursing homes (including skilled nursing facilities) to collect data for all types of adverse … events, near misses, and unsafe conditions. … Quality Indicators through free software programs that can help hospitals identify quality of care events … 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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pbrn.ahrq.gov/patient-safety/reports/candor-demo-program/candor/demo-program/index.html
August 01, 2022 - 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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pbrn.ahrq.gov/news/newsletters/e-newsletter/878.html
August 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … (Source: JAMA Network Open , Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem … include:
Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … to ask questions when something does not seem right
(1
(2
(3
(4
(5
SECTION D: Frequency of Events … Hospital management seems interested in patient safety only after an adverse event happens
(1
(2 … Shift changes are problematic for patients in this hospital
(1
(2
(3
(4
(5
SECTION G: Number of Events
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pbrn.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
December 01, 2017 - Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … requires the successful transfer of information from clinicians to the patient and family to reduce adverse … events and prevent readmissions.
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pbrn.ahrq.gov/patient-safety/reports/engage/interventions/medmanage.html
June 01, 2023 - Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … These tools will also help to identify patient behaviors that may be putting patients at risk for an adverse
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pbrn.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
May 01, 2023 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … While these are reportable events, we can assume the risks are more widespread; safety events in many … Trends in adverse event rates in hospitalized patients. JAMA 2022 Jul 12;328(2):173-83.
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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … mortality for pediatric surgical procedures
Rates of potentially avoidable complications and adverse … Events Composite)
PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Events Composite): http://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
Slide 17 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by
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pbrn.ahrq.gov/pbrn-registry/oregon-rural-practice-based-research-network
May 06, 2013 - diesease related interests: Access to care-dental services, drug sampling policies, medication errors and adverse … drug events, patient-centered primary care home, practice transformation, rural health delivery systems
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pbrn.ahrq.gov/news/blog/ahrqviews/comments-pso-draft-report.html
February 01, 2021 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … Although we still see too many events such as adverse drug reactions, infections, or falls, momentum
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pbrn.ahrq.gov/news/newsroom/press-releases/carbon-emissions.html
September 01, 2022 - AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
Newsletter
Events … Healthcare is both a significant contributor to climate change and responsible for managing the adverse … “Extreme weather events, declining air quality, and growing food and water insecurity now threaten healthcare
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pbrn.ahrq.gov/patient-safety/settings/hospital/match/index.html
April 01, 2023 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … process can detect and avert most medication discrepancies, potentially avoiding a large number of adverse … drug events and related costs for care of affected patients.