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pbrn.ahrq.gov/hai/cusp/modules/patient-family-engagement/index.html
July 01, 2018 - How to communicate an adverse event to patients and family members.
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … , and surgeon, along with a lack of familiarity with the new equipment as an important cause of the adverse
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - events and close calls. … events, and near-misses. … events. … • Eliminating Wrong Site Surgery
and Procedure Events.
• MHS Leadership Engagement. … drug events (ADEs).
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.html
August 01, 2022 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … advance the implementation of a transparent and just response to those who have been injured due to an adverse … team at every phase of CANDOR development, including during tool synthesis, training, and stakeholder events
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pbrn.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
July 01, 2019 - More topics in this section
News
Newsroom
Blog
Newsletter
Events … reducing the use of acute and institutional care, eliminating duplication of services, and reducing adverse … events resulting from conflicting management. … investing in research to improve diagnosis in each of the “Big Three” conditions: cancer, vascular events … https://www.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-chui.html
March 01, 2022 - As a result, adverse drug events (ADEs) are frequent, costly, and potentially life-threatening,” according
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
August 01, 2022 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … improvement metrics, which allows for improvement of CANDOR processes, and prevention of similar harm events … adverse patient events by promoting transparency and a fair and just culture. … Celebrating staff for reporting CANDOR (and other) events, such as near misses and unsafe conditions. … Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-sept2013.pptx
January 01, 2013 - TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Analysis of sentinel events … failure cited as a primary contributing factor in nearly 80 % of over 6,000 root cause analyses of adverse … events and close calls.
17
(Cost) Benefits of TeamSTEPPS
Decreased malpractice claims
Decreased … insurance premiums
Decreased litigation
Reduced rate of adverse drug events (from 30 to 18 per 1,000 … TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS
TeamSTEPPS in
Long-Term Care
Upcoming TeamSTEPPS Events
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-final-es.pdf
January 01, 2021 - The three measures that improved most reflect fewer adverse events
in nursing homes (two measures) and … fewer adverse drug events involving the blood thinner
heparin in hospital settings. … 2018, the incident rates of end stage renal disease due to diabetes
decreased 48% from 526 to 273.1 events … Alaska Native, Black, and White
populations, with respective incident rates of 273.1, 372.2, and 152.2 events … Hispanic communities
were still more than double the rates in non-Hispanic White communities (142.8
events
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - Defects (CUSP Element)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to shoulder dystocia … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events … Sample scenario:
· Shoulder dystocia
· Shoulder dystocia training can be effective at reducing adverse
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pbrn.ahrq.gov/patient-safety/patients-families/patient-family-engagement/index.html
April 01, 2018 - Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … Reconciliation
Learn about the processes that help detect and prevent medication discrepancies and adverse … drug events.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
January 01, 2014 - Adverse drug events occur in 15% or more of older
patients presenting to offices, hospitals, and extended … Although patient safety initiatives focus mainly on
inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians,
hospital … Events treated in
Adult ambulatory medical care visits due to adverse effects of medical care
per 1,000 … Reducing the risk of adverse drug events in older adults.
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pbrn.ahrq.gov/news/newsletters/e-newsletter/861.html
April 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Understanding patient and clinician reported nonroutine events in ambulatory surgery. … Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex
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pbrn.ahrq.gov/patient-safety/patients-families/index.html
June 01, 2023 - Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … Reconciliation
Learn about the processes that help detect and prevent medication discrepancies and adverse … drug events.
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pbrn.ahrq.gov/news/blog/ahrqviews/unhealthy-alcohol-use-during-covid19.html
April 01, 2021 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … spectrum of alcohol misuse from risky or hazardous drinking to alcohol use disorder, is associated with adverse
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pbrn.ahrq.gov/research/findings/final-reports/index.html
June 01, 2023 - : Older Adults Publication Date: August 2022
Management of Direct Anticoagulants to Lower Adverse … Events in Atrial Fibrillation (MODL-AF) ( application/pdf 412143 ) Principal Investigators: King
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
March 01, 2023 - Simulation is a technique that mimics real-world clinical events in a training environment so clinicians
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
May 01, 2017 - unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse … Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events and the contribution of EFM use, EFM interpretation, and communication of EFM findings
· Unit … can decide its approach to debriefing events based on seriousness of event, expertise available, and … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-031121.pdf
July 22, 2021 - IHS • Enhanced Adverse Event Reporting Capabilities: IHS Safety
Tracking and Response (I-STAR) system
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pbrn.ahrq.gov/news/blog/ahrqviews/ahrq-digital-healthcare.html
February 01, 2024 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … It was an improbable endeavor to transform a field built on paper and adverse to change.