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Showing results for "adverse events".
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1401. 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.

1402. Module 1: Preventing Pressure Injuries in Hospitals (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
      July 12, 2017 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events

1403. Indwelling Urinary Catheter Insertion Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion-notes.docx
      April 01, 2022 - This should be a minimum of annually, whenever new products or processes are introduced or when adverse … These events evoke a visceral response and serve as a lesson to prevent similar mistakes in the future … mindfulness is as a flexible state of mind “engaged in the present with acute awareness of external events

1404. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-206-fullreport.pdf
      November 01, 2019 - In States where the denominator is large (at least 2,000 events), the reliability is very good; observed … However, in Utah, where the denominator is 672 13 CT imaging events, reliability was lower … This suggests that this measure should be used in health plans with over 2,000 CT imaging events in … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the … Sedation and general anesthesia in children undergoing MRI and CT: Adverse events and outcomes.

1405. Nutritional Research Series: Volume 5: Comparison of Translational Patterns in Two Nutrient–Disease Associations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp5.pdf
      October 01, 2011 - The trials were expensive to conduct, and in some cases, they identified adverse effects of nutrient … Figure 1 describes alternative scenarios for the possible cascade of translational events. … Vitamin E supplementation and cardiovascular events in high-risk patients. … Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS) … For randomized trials, we extracted number of events in the intervention and control groups.

1406. 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

1407. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
      January 01, 2024 - diagnoses; • Delay in proper treatment or preventive services; • Medication errors and preventable adverse … drug events; 3 R01HS024859 What is Patient Safety in the Medical Home? … Primary care workers anticipated safety events by thinking about the information they may be missing … that primary care workers used omissions as a cognitive representation to anticipate unwanted safety events … Agency for Healthcare Research and Quality, Rockville, MD http://archive.ahrq.gov/news/events/other

1408. Surgical Complication Prevention Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-surgcomp.pdf
      December 01, 2017 - Some studies have found 3 percent to 27 percent of surgical patients suffer from a surgical adverse … The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

1409. CHCANYS Participation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/chcanys-qi-primer.pdf
      August 01, 2017 - If the team’s overall aim is at a system level (for example, "Reduce adverse drug events in critical … team members may find that focusing for a time on a smaller part of the system (for example, "Reduce adverse … drug events for critical care patients on the cardiac service by 30% within 12 months") will help them

1410. 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

1411. Anticipatory Guidance Regarding Hydroxyurea Treatment for Children With Sickle Cell Anemia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-213-fullreport.pdf
      January 01, 2019 - Hydroxyurea is indicated for pediatric patients with SCA who have recurrent vaso‐occlusive events, including … even more pronounced in older children with SCA, as they are hospitalized more often for the pain events … • Hydroxyurea works in all age groups to prevent acute events and chronic organ dysfunction. … complications have been associated thus far with hydroxyurea use in children, though research about adverse … Impact of hydroxyurea on clinical events in the BABY HUG trial. Blood 2012; 120(22):4304‐10.

1412. QDR 2014: Chartbook for Hispanic Health Care, Part 1 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt1.pdf
      October 01, 2015 - same time, several racial and ethnic disparities in rates of childhood immunization and rates of adverse … events associated with procedures were eliminated, showing that elimination is possible

1413. Best Practices in the Diagnosis and Treatment of Cellulitis and Skin and Soft Tissue Infections
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/cellulitis-slides.pptx
      November 01, 2019 - cure in evaluable population: 95% for TMP/SMX and 86% for placebo (p < 0.001) TMP/SMX associated with adverse … events in ~10% of patients 16 AHRQ Safety Program for Improving Antibiotic Use – Acute Care Cellulitis

1414. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI (July 9, 2013) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-transcript.html
      December 01, 2017 - they released just this past February, we know that, for example, in 2010, there were 802 sentinel events … reported to the Joint Commission, and 82 percent of those events listed communication issues as one … of the key root causes contributing to those events.  … Similarly, they were involved in 61 percent of events in 2011 and 59 percent of events in 2012.  … It increases their risk of poor outcomes and adverse events.

1415. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/health-literacy-pfe-transcript.doc
      July 09, 2013 - they released just this past February, we know that, for example, in 2010, there were 802 sentinel events … reported to the Joint Commission, and 82 percent of those events listed communication issues as one … of the key root causes contributing to those events. … Similarly, they were involved in 61 percent of events in 2011 and 59 percent of events in 2012. … It increases their risk of poor outcomes and adverse events.

1416. Practice and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
      May 01, 2024 - California, San Francisco; School of Medicine, Family Medicine Develops a tool for patients to report adverse … drug events (ADEs) to their ambulatory care teams. … interventions, and decrease health disparities, in States with a high prevalence of preventable cardiovascular events

1417. Assess and Adapt: Understanding the Science of Safety and Reliability (June 3, 2014) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-transcript.html
      December 01, 2017 - On average, every patient who's admitted to an intensive care unit has or suffers an adverse event. … organization and that way that those systems are put together really either hinders or helps the occurrence of adverse … events and poor patient outcomes. … very good at recovering when things go wrong, but we're not always that good at learning about why events

1418. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-transcript.doc
      June 03, 2014 - On average, every patient who’s admitted to an intensive care unit has or suffers an adverse event. … organization and that way that those systems are put together really either hinders or helps the occurrence of adverse … events and poor patient outcomes. … very good at recovering when things go wrong, but we’re not always that good at learning about why events

1419. Making Healthcare Safer Practices: 15. Care Transitions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/care-transitions-1.pdf
      March 01, 2020 - adequate discharge arrangements can lead to costly and unnecessary hospital readmissions, preventable adverse … events, and drug-related errors.1-12 For example, in 2008 nearly one-fifth of Medicare beneficiaries … Safety lapses can result in negative clinical outcomes,1-4 preventable adverse events,5-9 and avoidable … The incidence and severity of adverse events affecting patients after discharge from the hospital. … that includes resources to address areas of the discharge process that are predisposed to result in adverse

1420. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Seizure: Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
      November 01, 2019 - Drivers of Overuse Seizures can be stressful events that may prompt a parent to seek the assistance … EHRs may be limited by interoperability with other providers’ EHRs that may likewise capture imaging events … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the … Sedation and general anesthesia in children undergoing MRI and CT: Adverse events and outcomes.