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81. Universal ICU Decolonization: An Enhanced Protocol | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/hai/universal-icu-decolonization/index.html
    September 01, 2013 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Safety and Adverse Events The REDUCE MRSA Trial (Randomized Evaluation of Decolonization … Safety and Adverse Events Authors University of California Irvine Susan Huang, MD, MPH Adrijana

82. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Do they believe the organization is aware of all the patient harm events? … Have they heard of events that should have been reported but were not reported? … Other methods of reporting CANDOR events may include in-person reporting. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.

83. Board and Senior Leadership PowerPoint Presentations on the AHRQ Quality Indicators (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
    October 01, 2015 - • AHRQ QIs are indicators of hospital quality and adverse events that patients may experience as … • Pediatric Quality Indicators (PDIs) reflect quality of care inside hospitals and adverse events … • The PSIs are a set of 18 hospital-level indicators of safety-related adverse events following operations … and Safety • The PDIs are a set of 16 indicators that reflect quality of care inside hospitals and adverse … • PDIs measure events likely preventable through changes at the system or provider level.

84. Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/research/findings/studies/index.html?page=484
    January 01, 2024 - Drug Events (ADE) (321) Adverse Events (737) Alcohol Use (61) Ambulatory Care and Surgery … Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention Braithwaite S , Friedman … events. … events. … Keywords: Adverse Events, Hospitals, Medical Errors, Patient Safety, Quality Indicators (QIs)

85. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
    May 01, 2016 - events. … drug events. … events. … These adverse events are relevant because obstetric and perinatal-related claims are among the most … An ACEx2 program differs from other disclosure and offer models “because it focuses on adverse events

86. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
    May 01, 2017 - 3 SAY: Further, EFM interpretation and management is a common issue in litigation involving adverse … individual staff skills with respect to EFM interpretation may not be enough to reduce perinatal safety events … Perinatal Care Electronic Fetal Monitoring 8 SAY: A unit can decide its approach to debriefing events … events. … • Past adverse events related to EFM use. • Synergy with related or similar initiatives (e.g., initiatives

87. Rapid Response for Perinatal Safety: Slide Presentation | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-slides.html
    July 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Slide 14: Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse events … Have a process in place to review serious maternal or neonatal adverse outcomes. … Consider these factors: Unit data suggesting adverse events or near misses that may have been minimized … Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to

88. New Toolkit Can Improve Post-Surgery Complications and Enhance Patient Recovery | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsletters/e-newsletter/870.html
    June 01, 2023 - section News Newsroom Blog Newsletter AHRQ News Now Events … Researchers found that the interventions could prevent more than 3,100 ASCVD events over 10 years and … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Associated With Financial Distress An analysis of more than 132,000 individuals’ credit reports showed adverse … Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog

89. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
    May 01, 2017 - Professional Liability EFM interpretation and management are a common issue in litigation involving adverse … events, and the contribution of EFM use, EFM interpretation, and communication of EFM findings. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events 17 AHRQ Safety Program for Perinatal Care Electronic Fetal Monitoring 17 Unit Next Steps … Past adverse events related to EFM use Synergy with related or similar initiatives Interest and enthusiasm

90. Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/research/findings/studies/index.html?page=1
    January 01, 2024 - Drug Events (ADE) (321) Adverse Events (736) Alcohol Use (61) Ambulatory Care and Surgery … events. … events were rare. … Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse events. … Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse

91. Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/research/findings/studies/index.html?page=2
    January 01, 2024 - Drug Events (ADE) (321) Adverse Events (737) Alcohol Use (61) Ambulatory Care and Surgery … events. … events were rare. … Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse events. … Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse

92. Monitoring for Perinatal Safety: Electronic Fetal Monitoring: Facilitator Guide | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
    July 01, 2023 - unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse … Informal debriefings can be used by the clinical team immediately following a near miss or actual adverse … Finally, unit staff should disclose any unintended outcomes related to EFM use using unit policy for adverse … events. … Past adverse events related to EFM use.

93. Resource List - AHRQ Hospital Survey (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
    April 01, 2023 - • Implement a Care for the Caregiver program for providers involved in adverse events. … • Investigate and analyze an adverse event to learn from it and prevent future adverse events. … These organizations consistently minimize adverse events despite carrying out intrinsically complex and … Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primers/primer … Patient Safety Primer: Medication Errors and Adverse Drug Events 23.

94. Major Hospital Quality Measurement Sets | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/talkingquality/measures/setting/hospitals/measurement-sets.html
    February 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … The Patient Safety Indicators (PSIs) identify adverse events occurring during hospitalization. … They provide information on potential in-hospital complications and adverse events following surgeries

95. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
    talkingquality.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
    January 01, 2024 - Forty-five percent of the errors had adverse consequences. … events. … Confronting an adverse medical event collaboratively helped both patients and providers with patients … Patient perspectives of patient--provider communication after adverse events. … Adverse events in primary care identified from a risk- management database.

96. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
    talkingquality.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
    January 01, 2004 - Because oral anticoagulants are associated with preventable adverse events at disproportionately high … events,4, 37 such as thrombotic events (under-treatment) or bleeding (over- treatment). … events are common18 and warfarin is involved in preventable adverse drug events at rates disproportionate … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse drug events in ambulatory care. NEJM 2003 348(16):1556– 64. 19.

97. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - events … • Implement a Care for the Caregiver program for providers involved in adverse events. … • Investigate and analyze an adverse event to learn from it and prevent future adverse events. … These organizations consistently minimize adverse events despite carrying out intrinsically complex … drug events (ADEs).

98. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
    October 01, 2017 - Perinatal Safety 13 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated Debrief among clinical team after rapid … Response Call Log can facilitate a debrief Have a process in place to review serious maternal or neonatal adverse … Consider these factors: Unit data suggesting adverse events or near misses that may have been minimized … Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to

99. New Challenge Competition Launched To Update and Re-Create TeamSTEPPS Videos | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsletters/e-newsletter/813.html
    May 01, 2022 - section News Newsroom Blog Newsletter AHRQ News Now Events … Patient Safety found no evidence of the so-called “July Effect,” an increase in patient safety and adverse … events after the annual summertime resident changeover. … patient records abstracted and analyzed using the Medicare Patient Safety Monitoring System, changes in adverse … Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions

100. Rapidresponse Facguide (doc file)
     talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
     May 01, 2017 - This principle calls for L&D unit teams to evaluate their processes and learn from adverse events, errors … to the Rapid Response toolcall In addition, clinical teams can debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated. … Consider these factors: · Unit data suggesting adverse events or near misses that may have been minimized … Regularly debrief after rapid response events, and solicit ongoing feedback from staff and patients.