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Showing results for "adverse events".
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301. ABCS Aspirin Treatment for Secondary and Primary Prevention ASCVD
     pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-asa-measure.pptx
     April 01, 2016 - Measure Exceptions Adverse effect, allergy, or intolerance to Aspirin and Plavix (Clopidogrel). … Ischemic Vascular Disease Secondary prevention is where the evidence is the best Reduces risk of vascular events

302. Library of PCOR Resources | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/pcor/library-of-resources/index.html
     April 01, 2021 - database , which contains information on study participants and a summary of study outcomes, including adverse … events.

303. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
     January 01, 2021 - Care 1 INTRODUCTION High rates of readmissions are a major patient safety problem associated with adverse … events such as prescribing errors and misdiagnoses of conditions in the hospital and ambulatory care … As the evidence base for reducing adverse events and readmission from the primary care setting grows … role of the primary care team in improving quality and safety for patients and reducing postdischarge adverse … events and potentially preventable readmissions.

304. Selected Best Practices and Suggestions for Improvement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
     May 20, 2016 - abdominal surgeries, and is associated with significant risk of mortality between 14% and 50%.1 Other adverse … events include prolonged length of stay, subsequent surgeries and incisional herniation.2,3 • Proper

305. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
     May 01, 2017 - L&D Unit Safety 30 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … events. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … Factors to consider: Unit and malpractice claims data suggesting adverse events or near misses related

306. Selected Best Practices and Suggestions for Improvement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
     November 01, 2012 - foreign objects avoidable.1 • Retained foreign objects represent a serious and significant patient adverse … Chasing zero events of harm: an urgent call to expand safety culture work and customer engagement.

307. TeamSTEPPS® Teamwork Attitudes Questionnaire Manual | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/reference/teamattitudesmanual.html
     April 01, 2017 - safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … Adverse events may be reduced by maintaining an information exchange with patients and their families

308. Strategy 6E: Rapid Referral Programs | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6g-rapid-referral.html
     April 01, 2023 - Guidance Supplemental Items Using CAHPS Surveys CAHPS Databases Webcasts & Recent Events … possibility of delays in care, which generates greater anxiety and contributes to a greater risk of adverse

309. AHRQ Safety Program for Perinatal Care: Safe Medication Administration: Oxytocin (doc file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
     May 01, 2017 - parameters for provider notification and expectations for provider response ensures that signs of potential adverse … Defects (CUSP Module) Key Perinatal Safety Elements Examples Debrief and analyze near misses and adverse … events related to oxytocin use … · Unit can decide its approach to debriefing events based on seriousness of event, expertise available … Have a process in place to review severe maternal or neonatal morbidity and mortality events.

310. Module 1: Preventing Falls in Hospitals—Slide Presentation | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
     September 01, 2017 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem.

311. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
     May 01, 2017 - Studies have found that communication failures are the cause of up to 80 percent of operating room adverse … events. … Furthermore, lack of communication has resulted in serious patient safety events such as teams performing … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Voicing Concerns in the Surgical Environment Is Important Say: Studies show that many times when adverse

312. Strategies to Support Multiple IRBs (pdf file)
     pbrn.ahrq.gov/sites/default/files/docs/AHRQ-PBRN-Webinar-Strategies-to-Support-Multiple-IRB-091014.pdf
     September 10, 2015 - matter what • Waiving/Ceding oversight can be more efficient (modifications) and increase safety (adverse … events) • It may not accelerate study start-up • IRB chairs aren’t necessarily in favor of doing … September 30 PBRN Webinar on PBRN Research Good Practices (PRGPs) Report Visit http://pbrn.ahrq.gov/events … for webinar registration information and details on other upcoming PBRN-relevant events If … How to Submit a Question Obtaining CME Credit Upcoming Events PBRN and IRB Listservs: �Join the Conversation

313. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
     March 01, 2013 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse

314. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Safe Cesarean Section (doc file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
     May 01, 2017 - Learn From Defects (CUSP Module) Key Perinatal Safety Elements Examples Debrief and analyze adverse … events related to cesarean section … · 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

315. TeamSTEPPS 2.0 Module 3: Communication
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule3.pptx
     December 01, 2005 - * 2010 - 2012: Ineffective communication among top 13 root causes of sentinel events reported ** * ( … JC Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005) ** (JC … As a patient safety officer, I covered all our sentinel events, as well as any other adverse events, … which may not have been sentinel events. … We use it in our adverse event reports.

316. Nursing Home Workplace Safety Resource List (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
     January 01, 2023 - page provides tips to encourage staff members to report conditions that could lead to near-misses or adverse … events.

317. Preventing Pressure Injuries in Hospitals
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
     June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem. … Memo on never events, July 7, 2008.

318. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Root cause analysis is a systematic process during which all factors contributing to an adverse event … Surveys are also labor intensive and rely on staff members' recall of specific events.

319. TeamSTEPPS for Patients and Patient Engagement
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-march2013.pptx
     January 01, 2013 - Understanding role of patients in patient safety, as well as barriers to engaging patients, can help reduce adverse … events and improve quality of care Scobie and Persaud.

320. Train-the-Trainer Instructor Guide | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
     October 01, 2020 - Slide Time: 5 minutes Say: To illustrate why LEP patients are at risk of patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study. … is inspired by the 2006 book by John Kotter, Our Iceberg Is Melting: Changing and Succeeding Under Adverse … Our iceberg is melting: changing and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events