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preventiveservices.ahrq.gov/patient-safety/about/areas.html
February 01, 2018 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Learn about Patient Safety
Patient Safety and Quality Areas
Patient Safety News and Events … Team Training
Falls
Pressure Ulcers
Diagnostic Safety
Blood Clot Prevention and Treatment
Adverse … Drug Events
AHRQ Quality Indicators (QIs)
Page last reviewed February
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preventiveservices.ahrq.gov/data/resources/index.html?page=5
May 02, 2024 - Studies
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Access to Care
(4)
Adverse … Events
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Ambulatory
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By Payer
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By State
(3)
Children
(3)
Children
(1)
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preventiveservices.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
December 01, 2012 - Studies
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Events … After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023.pdf
January 01, 2023 - and is defined as harm to the patient after
discovery of the incident and any attempts to minimize adverse … For example, Medication or Other Substance events that were reported as
Adverse reaction in patient … extent of harm to the patient after discovery of the
incident and after any attempts to minimize adverse … extent of harm to
the patient after discovery of the incident and after any attempts to minimize adverse … decision to
prescribe medication despite known drug-drug interaction)
• Drug-drug, drug-food, or adverse
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preventiveservices.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Studies
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Events … Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse … Events Form (DOCX, 227 KB)
Gap Analysis Tool (DOCX, 382 KB)
The Four Moments of Antibiotic Decision
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanagement_webinar_slides.pdf
January 01, 2015 - • 2.3 billion prescriptions are prescribed by
primary care clinicians each year (CDC)
• Adverse drug … events result in as many as 4.5
million ambulatory visits each year 1
• Medication reconciliation … improves patient
safety and reduces adverse drug events:
– prescribing errors, medication contraindications … Adverse drug events in U.S. adult ambulatory medical care.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - ------------------------------------------------------------------- 9
How to prevent adverse events … one study.1 Of these adverse events, three-quarters could
have been prevented or ameliorated. … At this time, no
consensus exists on the single best method to prevent adverse events after
discharge … The incidence and severity of adverse
events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge
How does the IDEAL Discharge Planning strategy improve
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - mortality for pediatric surgical procedures
Rates of potentially avoidable complications and adverse … for Selected Procedures)
IQI 91 (Mortality for Selected Conditions)
PSI 90 (Patient Safety and Adverse … Events Composite)
PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … References
Slide 48
Sample Best Practices
Pressure ulcers represent an important patient adverse
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-roster-2023dec.pdf
December 21, 2023 - Medical Officer
Name Department/Agency Title
Michael Lee, Pharm.D.,
BCPS, CAPT, USPHS
IHS IHS Adverse … Events Coordinator, IHS Office of
Quality, Division of Quality Assurance and
Patient Safety
Phillippe
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
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Events … section
News
Newsroom
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Events … Reducing Adverse Events Related to Anticoagulants .
Implicit Bias Training .
Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .
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preventiveservices.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
March 01, 2021 - and Systemic Racism on Patient Safety
What is the impact of socio-economic status on the risk for adverse … events or patient safety events? … How can the impact of socio-economic status on patient safety events be measured? … How can audiovisual recordings of patient care events be created in a manner that is: HIPPAA complaint … How can adverse event detection be automated through the use of EHRs?
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Studies
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Events … section
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Events … Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis . … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality
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preventiveservices.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
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Events … The Standard for “Never Events”
There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - ”
· “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … questions when something does not seem right
1
2
3
4
5
9
SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported?
a. … Hospital management seems interested in patient safety only after an adverse event happens
1
2
3
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
November 03, 2022 - of our resource – Measure Dx: A
Resource To Identify, Analyze, and Learn From Diagnostic Safety
Events … IHS • Enhanced Adverse Event Reporting Capabilities
o IHS Safety Tracking and Response (I-STAR) is deployed … Current projects include working on overdue events
and development of standardized reporting at the
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preventiveservices.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - hospitals and nursing homes (including skilled nursing facilities) to collect data for all types of adverse … events, near misses, and unsafe conditions. … Quality Indicators through free software programs that can help hospitals identify quality of care events … Research suggests that adverse events affect patients with limited English proficiency more frequently … If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/890.html
November 01, 2023 - Studies
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Events … section
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Events … antibiotics within 48 hours of presentation and in 13 percent of hospitalizations patients experienced an adverse … time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse … events were rare.
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/907.html
April 01, 2024 - Studies
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Events … section
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Events … of team strategies and tools to improve performance and approaches to team-based error disclosure on adverse … events. … Articles featured this week include:
Transfusion-related errors and associated adverse reactions
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preventiveservices.ahrq.gov/patient-safety/reports/national-action-plans.html
February 01, 2018 - Studies
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AHRQ Views
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies
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preventiveservices.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - Studies
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Events … section
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Events … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality … Risk factors for opioid-related adverse drug events among older adults after hospitalization for major