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1381. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
      August 01, 2022 - physician to observe overt and many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting a case and receiving feedback.42 The study reported a significant reduction in adverse … events and near- misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency department

1382. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
      August 01, 2022 - physician to observe overt and many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting a case and receiving feedback.42 The study reported a significant reduction in adverse … events and near- misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency department

1383. History and Funding of PBRNs | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/communities/pbrn/history/index.html
      November 01, 2024 - science base of clinical care through systematic inquiry to better understand the health and health care events … PBRN Web Events —PBRN researchers, directors, and staff participate in ongoing discussions dedicated … pandemic influenza event. 7   Field testing of a new ambulatory care electronic Medication Errors and Adverse … Drug Events Reporting System (MEADERS). 8 References Lanier D. … Field test results of a new ambulatory care Medication Errors and Adverse Drug Events Reporting System

1384. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
      January 01, 2024 - Usability events were grouped into thematic categories: navigation/UI events, health literacy events … Adverse drug events and medication errors in Australia. … Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between Hospital

1385. Spreadnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
      June 02, 2025 - ASK: · How did the pilot CUSP team make a case for their project targeting adverse drug events?

1386. Improving Patient Safety with the Military Electronic Health Record (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Charles.pdf
      January 24, 2004 - permits physicians to record prescribed medications and view alerts for drug allergies or potential adverse … For more than 10 years, CHCS has issued alerts for potential adverse drug interactions and warnings … patient’s prescription history is viewed in real time and the system alerts providers to any potential adverse … This capability augments patient safety and the quality of medical care by reducing the likelihood of adverse

1387. Background for AHRQ Quality Indicators
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c3_pdi_staffpresentation.pptx
      January 01, 2006 - events that children, adolescents, and, where specified, neonatal patients may experience as a result … PDIs measure events likely to be preventable through changes at the system or provider level. … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … on: Comparison between our hospital and peer hospitals Our performance over time Volume and cost of events … You may also want to report the number of patients with the adverse event to make it more tangible to

1388. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
      September 01, 2016 - in the past 12 months, and about respondent perceptions of the frequency of events reported. … Watson Senior Vice President Michigan Health & Hospital Association 3 of adverse events and discussion … offers a way for PSO members to share accounts of patient safety events. … The alerts describe the reported events and provide information on how to prevent similar events. … Exploring relationships between hospital patient safety culture and adverse events.

1389. National Action Plans | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/national-action-plans.html
      February 01, 2018 - National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies

1390. Chapter 4: Defining Language Need and Categories for Collection, cont. | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/iomracereport/reldata4c.html
      August 01, 2021 - Are language barriers associated with serious medical events in hospitalized pediatric patients? … Language proficiency and adverse events in US hospitals: A pilot study. … through June 30, 2005, interpretation was provided in Superior Court for 77 languages across 83,548 events … , with 16 major languages accounting for most events ( New Jersey Courts, 2009 ). 20 Personal communication

1391. Final Progress Report: Engineering Highly Reliable Communication and Coordination Systems for High-Risk Patients, Referrals, and Tests (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/singer-benneyan-phillips-report.pdf
      January 01, 2025 - supported preoperative care process that frontloads the work to improve patient experience and reduce adverse … events, lengths or stay, and hospital readmissions. … Adverse drug events in ambulatory care. N Engl J Med. 2003 Apr 17;348(16):1556–1564. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … A classification of medical errors and preventable adverse events in primary care: A synthesis of the

1392. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
      November 01, 2020 - as well as from adverse drug reactions. … 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 … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.

1393. Exhibit 11. Importance measures on events in rank order of criticality | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.html
      April 01, 2018 - Importance measures on events in rank order of criticality Previous Page Next Page Table

1394. Appendix III (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiib.html
      June 01, 2010 - collection compared) Total Items/indicators: Six measures, each is a numeric sum of a number of adverse … tenure; they also found adequate paraprofessional and informal home care decreased the likelihood of adverse … health events. … Six measurement areas are: self-report of unmet need; satisfaction with care; morale, adverse health

1395. Final Progress Report: EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/vaughan-report.pdf
      January 01, 2024 - SCOPE Background: Older adults are a vulnerable population at high risk for medication adverse drug events … Potential Adverse Drug Interactions in the Emergency Room: An Issue in the Quality of Care. … Potentially inappropriate medications and adverse drug effects in elders in the ED.

1396. Client Functioning Measures and Gaps | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep3.html
      June 01, 2010 - Regardless, all programs strive to promote optimum client health and avoid preventable adverse health … promotion ix and the receipt of recommended health care services, but also the avoidance of serious adverse … In particular, the adverse relationship between disability and employment has been well established. … These include serious, reportable events that reflect a consensus regarding client health and safety, … Consistency and consensus are lacking with regard to HCBS-appropriate definitions of serious reportable events

1397. Assessing the Availability of the Preconception Component of High-Risk Obstetrical Services by Estimating the Use of Teratogenic Medications Before and During Pregnancy (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-233-fullreport.pdf
      August 07, 2018 - Additional adverse fetal effects that result in dysfunction of a formed organ or tissue include postnatal … maternal events. … We suggest availability of care is essential for women who are at risk of adverse pregnancy outcomes … The ability to minimize and/or prevent adverse fetal effects due to potentially teratogenic medication … Exposure to teratogens during pregnancy is associated with significant adverse outcomes and occurs with

1398. Learning from Errors in Ambulatory Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
      February 01, 2004 - drug events and preventable adverse drug events) occurred at a three-fold higher rate in children than … Incidence of adverse drug events and potential adverse drug events: implications for prevention. … Adverse drug events in hospitalized patients. JAMA 1997;277:301– 6. 3. … Medication errors and adverse drug events in hospitalized children. … Adverse sedation events in pediatrics: a Critical Incident Analysis of contributing factors.

1399. Prologue—Volume 1—Five Years Later—Are We Any Safer? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
      January 01, 2004 - the initial IOM goal for some injury sources (for example, Brigham & Women’s Hospital in Boston for adverse … drug events [ADEs]; Intermountain Health Care’s LDS Hospital in Salt Lake City for ADEs and for postoperative … injuries, and near misses, because of difficulties in recognizing, tracking, and summarizing these events … trigger systems), to successful interventions that addressed specific, single injury sources (e.g., adverse … drug events), to organizational structures (e.g., building a culture of safety; nursing roles; teamwork

1400. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.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