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www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
January 01, 2024 - Detecting adverse events for patient safety research: a review
of current methodologies. … Detecting Adverse Events Using
Information Technology. … Detection of adverse events using conflicts in the electronic medical record
(poster). … Using computerized data to identify adverse drug events in
outpatients. … Electronically screening discharge
summaries for adverse medical events.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
May 01, 2013 - tools to improve communication among patients, families, and clinicians
Discuss how to communicate an adverse … event
Introduction to Adverse Events
Adverse event: An injury to a patient caused by medical intervention … events happen
When an adverse even occurs, it can be difficult for a health care worker to take ownership … when, where, and why)
Document the event in the medical record
Next Steps in Responding to an
Adverse … events occur
Tools
Am I Ready To Become an Advisor?
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www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
December 01, 2014 - Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse … 9,200
0.28
Falls
MPSMS (2013)
In-Hospital Patient Falls
240,000
7.2
Obstetric Adverse … Events
PSI (2012)
OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) … Femoral Artery Puncture for Catheter Angiographic Procedures
59,000
1.8
MPSMS (2013)
Adverse … Events Associated With Hip Joint Replacements
21,000
0.63
MPSMS (2013)
Adverse Events Associated
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www.ahrq.gov/hai/cusp/modules/patient-family-engagement/alt-text-tab.html
September 01, 2013 - tools to improve communication among patients, families, and clinicians
Discuss how to communicate an adverse … event
Slide 22
Introduction to Adverse Events
Adverse event: An injury to a … events happen
When an adverse even occurs, it can be difficult for a health care worker to take ownership … event is essential
Slide 23
Immediate Response to an Adverse Event 3
Care for … events occur
Slide 28
Tools
Am I Ready To Become an Advisor?
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … institutions include how to:
Engage patients and families in disclosure communication following adverse … 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
January 01, 2004 - (e.g., preventable adverse events, medical errors) among elderly Medicare fee-for-
service (FFS) patients … men, while black
patients are more likely to suffer surgery-related and nursing-related adverse
events … These five adverse events are indicated with an asterisk in Table
5. … Table 4 further indicates that the probability of adverse patient safety events
vary by gender, race … Licensed nurse staffing and adverse events
in hospitals. Med Care 2003;41(1):142–52.
16.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
January 01, 2011 - 10
20
30
40
50
Pe
rc
en
t
Type of Physical Harm
Types of Physical Harm Experienced From
Adverse … Language proficiency and adverse events in
U.S. hospitals: a pilot study. … http://teamstepps.ahrq.gov/�
http://teamstepps.ahrq.gov/�
Summary
Adverse events that affect LEP … Language proficiency and adverse events in U.S. hospitals: a
pilot study. … Causes of Adverse Events for LEP and Culturally Diverse Patients
Systems and Strategies To Improve Safety
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - events—such as adverse drug events, falls, and pressure ulcers—occurred. … Incidence of adverse drug events and potential adverse drug events.
Implications for prevention. … Adverse drug events in hospitalized
patients. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S. … Adverse events in hospitals: methods for identifying events. Washington, DC: U.S.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - ■ 44% of adverse events were preventable. … ■ Potential decrease in adverse events being litigated, which can potentially
lead to lower malpractice … and
practitioners can use to respond in a timely, thorough, and just way to
unexpected patient harm events … Slide 16
6 – Facilitator Notes - Grand Rounds Presentation
Say:
A good response to adverse events … metrics, allowing for clarification and improvement of the
CANDOR processes and preventing similar harm events
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www.ahrq.gov/research/findings/studies/index.html?page=277
January 01, 2024 - Keywords: Blood Pressure, Diagnostic Safety and Quality, Adverse Events, Medical Errors, Electronic … This study examined the reported adverse events (AEs) involving cataract surgery in Massachusetts from … Patient harm in cataract surgery: a series of adverse events in Massachusetts. … Keywords: Adverse Events, Eye Disease and Health, Patient Safety, Risk, Surgery
Dabbous F , … Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - infections, adverse drug events, and injuries due to procedures,
as well as pressure ulcers and falls … For example,
measured adverse drug events continued to drop from 2014 to 2016, while measured pressure … Infections (CLABSI)
Clostridium difficile Infections
Falls
Obstetric Adverse Events
Pressure Ulcers … Rate of 21 MPSMS adverse events in the MPSMS sample provided by CMS,
including those in the Surgical … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number
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www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions3.html
June 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … , with more than one-third of these adverse events deemed preventable. 63 These adverse events are associated … events in the ICU.65 However, few evidence-based approaches are available to structure written or verbal … event related to the ICU-ward handoff, and most of these adverse events were rooted in communication
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
June 01, 2023 - academic medical centers, one survey 57 showed that 87 percent of residents recalled at least one adverse … Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event … , with more than one-third of these adverse events deemed preventable. 63 These adverse events are associated … events in the ICU.65 However, few evidence-based approaches are available to structure written or verbal … event related to the ICU-ward handoff, and most of these adverse events were rooted in communication
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
April 01, 2016 - Recent research shows a significant correlation between the frequency of adverse events and malpractice … events and promote better care for patients through candid, caring communication in the wake of an adverse … – Discuss efforts to improve communication and
response to adverse events to date, including the … event
• Number of adverse events reported >24 hours
after occurrence
– Severity level of adverse … Determine a return on
investment that ties to reduced adverse events.
14 – Implementation Guide for
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - infections, adverse drug events, and injuries due to
procedures, as well as pressure ulcers/pressure … For
example, measured adverse drug events continued to drop from 2014 to 2017, while measured
pressure … Preliminary
2017
2019 Goal
(20%
Reduction
of each
HAC)
Adverse Drug
Events
33.7 30.0 27.1 … National number of adverse events captured by PSIs 18 and 19 on obstetric
injury and national number … Due to changes in how some conditions and adverse events are described in ICD-9 and
ICD-10, the data
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www.ahrq.gov/funding/grantee-profiles/grtprofile-landrigan.html
November 01, 2021 - events that we’ve been experiencing in this country for the past several decades." … events. … In an initial nine-center study , rates of preventable adverse events fell 30 percent following implementation … events due to medical care. … Landrigan developed and tested a new trigger tool to identify adverse events in pediatric patients.
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www.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
September 01, 2020 - (continued)
Slide 10: Causes of Adverse Events for LEP and Culturally Diverse Patients
Slide 11: … Language proficiency and adverse events in U.S. hospitals: a pilot study. … Types of Physical Harm Experienced From Adverse Events by English Speaking and LeP Patients. … Common Causes: Adverse Events for LEP Culturally Diverse Patients
Use of Family Members/Friends … Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care .
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.html
August 01, 2022 - to establish an initiative to help States and health care systems test new models of care delivery, adverse … previously collected patient complaint data suggests that patient complaints may be a predictor of adverse … events. … drug events. … that would also be Automatically Compensable Events (ACEx2), a list of 18 events meeting these criteria
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www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - and other Federal partners—realized that hospitals needed to understand specifically how and where adverse … events were occurring in order to prevent them. … Therefore, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered … Features
The QSRS:
Offers an expanded array of adverse event measures. … Provides additional detail for the most frequently occurring events.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
February 21, 2008 - of
these, or 3.8 million events, are thought to be preventable.9 Clearly, adverse drug events that … events in the ED is high.9
One analysis of adverse drug events reported to a national database showed … events of any other
clinical environment, adverse drug events that occur in the ED are clearly a significant … The nature of
adverse events in hospitalized patients. … The clinical pharmacist’s role
in preventing adverse drug events.