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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
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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/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - Reporting Patient Safety Events
(Never, Rarely, Sometimes, Most of the time, Always, Does Not Apply … Hospital management seems interested in patient safety only after an adverse event happens. … Reliability of this composite measure—Cronbach’s alpha (3 items) = .72
Number of Events Reported … In the past 12 months, how many patient safety events have you reported?
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pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-2-slides.html
February 01, 2019 - Antibiotics can cause harm to residents
High risk of side effects and adverse events. … of commitments and activities designed to "optimize the treatment of infections while reducing the adverse … events associated with antibiotic use."
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pbrn.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Or a patient having wisdom teeth removed may have a strong adverse reaction to the sedation and require
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-t-taq-questionnaire.pdf
May 31, 2023 - Adverse events may be reduced by
maintaining an information exchange
with patients and their families
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/dental.html
March 01, 2014 - This communication failure results in an adverse event. … If given to a pregnant woman, this medication can have adverse effects on the fetus.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-dec2013.pptx
January 01, 2013 - Healthcare
& TeamSTEPPS at JHU
TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
Upcoming TeamSTEPPS Events … in pt. harm (Abstoss et al., 2011)
Rates of RRS activations that resulted in codes (Donahue, 2011)
Adverse … Use of evidence-based practice
Handoffs
Efficiency
Reduced care delays
Decision time
Safety outcomes
Adverse … events with teamwork and communication related root causes
Infection rates
Other harm related outcomes
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.pdf
May 01, 2017 - L&D
unit staff are able to focus on patient care and
have confidence that untoward events (change … learning
from defects for oxytocin administration
include—
• Debriefing and analyzing near
misses and adverse … 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
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/teamattitude.pdf
December 09, 2015 - Adverse events may be reduced by maintaining an
information exchange with patients and their families
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pbrn.ahrq.gov/news/newsletters/e-newsletter/906.html
March 01, 2024 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … treatment options and have the strongest evidence base for improving ADHD symptoms but are associated with adverse … events, such as appetite suppression.
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pbrn.ahrq.gov/teamstepps/instructor/reference/teamattitude.html
April 01, 2017 - 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/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
August 07, 2012 - Poor communication among staff is a root cause of many patient adverse and sentinel events.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule10.pptx
January 01, 2004 - Slide 19)
Measure Level IV - Results
Provide information on potential in-hospital complications and adverse … events
Can help identify potential adverse events that might need further study
Include indicators … The PSIs are a set of measures that provide information about potential in-hospital complications and adverse … events following surgeries, other hospital or care procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse events that might require further study
-
pbrn.ahrq.gov/news/newsletters/e-newsletter/867.html
June 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study .
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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
July 01, 2023 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … If successful, maternal and neonatal adverse events will decrease.
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pbrn.ahrq.gov/news/newsroom/press-releases/reduced-ltc-antibiotic-use.html
February 01, 2022 - AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
Newsletter
Events … facilities also significantly reduced use of fluoroquinolones , a class of antibiotics known to cause adverse
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pbrn.ahrq.gov/news/newsroom/case-studies/index.html
February 01, 2024 - 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 … Impact Case Study Identifier: 2023-01 AHRQ Product(s): SHARE Approach Topic(s): Access to Care, Adverse … Drug Events (ADE), Care Coordination, Chronic Conditions, Clinician-Patient Communication, Diabetes,
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanage_quickstartbrochure.pdf
December 15, 2016 - medication reconciliation and
medication management are well documented.2-5 One study
found that adverse … drug events result in as many as 4.5 million
ambulatory visits (office and emergency department) each … It will also help you identify patient behaviors
that may be putting them at risk for an adverse drug … with patients and families to prepare the medication list and
identify patients at risk for safety events … Adverse drug events
in U.S. adult ambulatory medical care.