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Showing results for "adverse events".
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  1. pbrn.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
    August 22, 2023 - The board’s tracking of adverse events and delineated types of errors (including near misses) - focus … ensure they have/are part of QAPI efforts where appropriate and understand how to identify and report events … complaints in cardiology and cardiac surgery • Patient mortality triple the norm and rise in adverseevents and claims (often lagging indicators) • Patient complaints • Culture of Non- transparency … • Could a department hide embarrassing events from management and the board?
  2. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
    May 01, 2017 - L&D unit staff are able to focus on patient care and have confidence that untoward events (change in … order; this is done to ensure that no steps are missed rather than to dictate a rigid sequence of events … Fostering a culture that supports debriefing by the clinical team immediately after a near miss, an adverse … • Having a process in place to review severe maternal or neonatal morbidity and mortality events … Factors to consider— o Unit and malpractice claims data suggesting adverse events or near misses
  3. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
    August 20, 2015 - improvement metrics, which allows for improvement of CANDOR processes, and prevention of similar harm events … Over time, the organization must continue to encourage frontline staff to report CANDOR events and other … 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.
  4. pbrn.ahrq.gov/patient-safety/news-events/psaw-2019/index.html
    July 01, 2022 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … https://www.ahrq.gov/patient-safety/news-events/psaw-2019/index.html  
  5. pbrn.ahrq.gov/data/infographics/index.html
    March 01, 2024 - Family Premiums for Employer-Sponsored Health Insurance Growing Pain of Spinal Stenosis Adverse … Drug Events Occurring in U.S.
  6. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
    April 12, 2018 - . ■ Answer your questions. 1 in 9 emergency department admissions are related to an adverse drug
  7. pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide.html
    November 01, 2018 - supporting the need for a TeamSTEPPS Intervention could originate from a variety of sources, including adverse … Available organizational data, (e.g., adverse event and near miss reports, AHRQ Patient Safety Culture … so that facilities may also use the Guide to develop TeamSTEPPS Action Plans in response to sentinel events
  8. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
    April 10, 2018 - • Adverse drug events • Unsafe medicine issues • Medicine adherence • Satisfaction • Reported use … We will use several measures to evaluate effectiveness: How many adverse drug events occur pre- and
  9. pbrn.ahrq.gov/funding/policies/nofoguidance/index.html
    January 01, 2024 - Surveillance, measurement, detection, and reporting of patient safety events. … Determination of the clinical efficacy and effectiveness of preventive interventions, including unintended adverse
  10. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pdf
    May 22, 2013 - • Nearly 20 percent of patients experience an adverse event within a month of discharge, of which ¾ … could be prevented • Common complications post-discharge are adverse drug events, hospital-acquired
  11. pbrn.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
    August 01, 2021 - this section News Newsroom Blog AHRQ Views Newsletter Events … Clearly, the COVID-19 pandemic has further illuminated the scale and adverse impacts of this problem,
  12. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
    May 01, 2017 - for Ambulatory Surgery 6 Studies show that communication failures are the cause of 80 percent of adverse … for the entire team Cards were placed in every operating room Reduced wrong-site surgeries and other adverseevents Increased staff morale Reduced nursing turnover 4Shepard S. … Ensures all team members are on the same page Confirms critical information Provides a place to discuss adverse … or potentially adverse events that occurred Facilitates discussion of how to stop problems from reoccurring
  13. pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2014-materials/teamstepps-monthly-webinar-dec2014.pptx
    January 01, 2014 - 1 05.2 Page ‹#› TeamSTEPPS® TeamSTEPPS for Patients Slide ‹#› 11 Research Aims Identify L&D events … (Mutual Support) Adverse events may be reduced by maintaining an information exchange with patients and … TEAMSTEPPS 05.2 Mod 1 05.2 Page ‹#› TeamSTEPPS® TeamSTEPPS for Patients Slide ‹#› Upcoming TeamSTEPPS Events
  14. pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
    December 01, 2020 - Importance of Patient Safety Mortality Prevalence Cost Findings on Patient Safety Improving Trend: Adverse … Drug Events With Heparin and Factor Xa Improving Trend: Inpatient Adverse Drug Events With Anticoagulants
  15. pbrn.ahrq.gov/sites/default/files/docs/AHRQ%20PBRN%20Webinar%20Slides_JACM%20PBRN%20Issue_042914.pdf
    June 01, 2014 - Self-management behaviors (diet, exercise)  Functional status & days confined to bed  Detection of adverse … / potentially adverse events  Cost-effective:  $65,167 for set-up and ongoing costs  $32,333 … research issue • November: Evaluation of Practice Transformation Visit http://pbrn.ahrq.gov/events … for information on all upcoming PBRN-relevant events If you have a suggestion for a new topic … of Tools� Conclusions Acknowledgements How to Submit a Question Obtaining CME Credit Upcoming Events
  16. pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
    April 01, 2023 - Staff can use this decision tree when analyzing an error or adverse event in an organization to help … events and close calls. … events, and near-misses. … These organizations consistently minimize adverse events despite carrying out intrinsically complex and … drug events (ADEs).
  17. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
    July 12, 2018 - diagnostic errors were a chief concern in outpatient visits 1 in 9 ED admissions are related to an adverse
  18. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module10/igmeasure.pdf
    January 01, 2004 - PSIs are a set of measures that provide information about potential in- hospital complications and adverseevents (outcomes) following surgeries, procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse events that might require further … also include indicators for complications occurring in-hospital that may represent patient safety events … Such events can be mitigated with the implementation of TeamSTEPPS tools and strategies.
  19. pbrn.ahrq.gov/news/blog/ahrqviews/addressing-historical-racism.html
    April 01, 2021 - this section News Newsroom Blog AHRQ Views Newsletter Events
  20. pbrn.ahrq.gov/news/blog/ahrqviews/uneven-impact-covid19.html
    December 01, 2021 - this section News Newsroom Blog AHRQ Views Newsletter Events

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