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pbrn.ahrq.gov/diagnostic-safety/research/index.html
March 01, 2024 - Learning more about the link between diagnostic errors and outcomes, including adverse events.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - learning from defects for oxytocin administration include—
Debriefing and analyzing near misses and adverse … Having a process in place to review severe maternal or neonatal morbidity and mortality events. … key safety elements of learning from defects are the same as for oxytocin:
Debriefing near misses and adverse … events related to magnesium sulfate use. … Consider these factors:
· Unit data suggesting adverse events or near misses related to oxytocin, magnesium
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse … 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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_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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pbrn.ahrq.gov/news/newsletters/e-newsletter/896.html
January 01, 2024 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Changes in hospital adverse events and patient outcomes associated with private equity acquisition .
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Ways to reduce obstetrical adverse events include improving teamwork and communication
among care teams … Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … EARLY IMPACTS
The most recent root cause analyses of adverse events
and near-misses indicated that … poor communication is
no longer a root cause; in fact, near-misses and adverse
events attributed to … The weighted
adverse events included in the measure are in-house maternal death, in-house
neonatal
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pbrn.ahrq.gov/sops/international/hospital/translators.html
October 01, 2014 - The survey also includes questions asking for an overall rating on patient safety and the number of events … Hospital management seems interested in patient safety only after an adverse event happens. … usually show interest in patient safety—they show interest in patient safety only when there is an adverse … Frequency of Events Reported
( More about this item: Refers to reports made to someone in authority … The term "rating" can be used instead of "grade." )
Number of Events Reported
(No event reports,
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pbrn.ahrq.gov/news/newsletters/e-newsletter/886.html
October 01, 2023 - 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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pbrn.ahrq.gov/health-literacy/improve/pharmacy/tools.html
January 01, 2024 - (MTM) is a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse … events, and improve medication adherence.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
April 01, 2011 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … be prevented
Common complications post-discharge are adverse drug events, hospital-acquired infections … have been prevented or ameliorated.1
Common post-discharge complications include adverse drug events … The incidence and severity of adverse events affecting patients after discharge from the hospital. … events and prevent readmissions.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-april2016.pptx
January 01, 2016 - 05.2 Page ‹#›
TeamSTEPPS®
Clinical Performance & Safety Culture
Slide ‹#›
Upcoming TeamSTEPPS Events … 05.2 Page ‹#›
TeamSTEPPS®
Clinical Performance & Safety Culture
Slide ‹#›
Upcoming TeamSTEPPS Events … Register at: https://tslms.org
Learn more and register for all events at www.TeamSTEPPSportal.org … healthcare
Optimizing patient outcomes by improving communication and other teamwork skills
Reducing adverse … patient events related to communication breakdowns and/or poor teamwork
TEAMSTEPPS 05.2
Mod 1 05.2
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - fractures.3,9
Staff with requisite training and supplies available to respond to magnesium-related adverse … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to magnesium sulfate use … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events including respiratory depression
2.
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pbrn.ahrq.gov/news/newsletters/e-newsletter/877.html
August 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic
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pbrn.ahrq.gov/news/newsletters/e-newsletter/873.html
July 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … the Society of Thoracic Surgeons’ (STS) postoperative cardiac surgery guidelines is associated with adverse … events, according to an AHRQ-funded study in the Journal of Thoracic and Cardiovascular Surgery .
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pbrn.ahrq.gov/sites/default/files/docs/DARTNetDataWebinar.pdf
August 18, 2015 - in eGFR
oChange in ACR
Patient outcomes that matter
oESRD
oDeath – linkage to NDI
CKD - Adverse … Outcomes
Adverse effects
oNumber of individuals who develop
hyperkalemia
oRate of hip, forearm … Awareness, Assessment, Adaptation, Acceleration-A Guidance
Document
Visit http://pbrn.ahrq.gov/events … for webinar
registration information and
details on other upcoming PBRN-relevant events
If you … Optimal Set*
Summary and Conclusions
Blurring QI and Research - CKD
CKD – Positive Outcomes
CKD - Adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/teamattitude.pdf
March 21, 2014 - Adverse events may be reduced by maintaining an
information exchange with patients and their families
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/carnahan.pdf
January 01, 2014 - Description
Antipsychotics have limited effectiveness in
dementia and increase risk of mortality and other
adverse … events.
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pbrn.ahrq.gov/hai/universal-icu-decolonization/universal-icu-overvw.html
September 01, 2013 - Safety and Adverse Events
Introduction to the Protocol
The Universal ICU Decolonization
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pbrn.ahrq.gov/teamstepps/officebasedcare/handouts/teamattitudes.html
December 01, 2015 - Adverse events may be reduced by maintaining an information exchange with patients and their families