Results

Total Results: 1,763 records

Showing results for "adverse events".
Users also searched for: patient safety indicators

1401. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
      March 01, 2017 - Slide 28: Communicating Adverse Events Say: Communication following an adverse event can been especially … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … Slide 30: How To Communicate About An Adverse Event Say: It is important to remember that residents … and family members can experience a number of emotions when an adverse event occurs, so communication … about an adverse event should be compassionate and sensitive.

1402. Appendix 3: Data Abstraction (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix3-data-abstraction.xlsx
      June 24, 2022 - utilization; NEST_data • The specific data elements required to assess performance and outcomes (including adverse … events and their timing) in the course of the disease or treatment; NEST_data • The appropriate settings … expectations or preferences will providers and patients be expected to have regarding benefits and adverse … NAM2019 Likelihood that beneficial or adverse effects would be reported or observed? … expectations or preferences will providers and patients be expected to have regarding benefits and adverse

1403. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
      April 27, 2022 - The remaining 2 studies (Giardina et al29,30) analyzed existing data sets of patient reports of adverse … events and patient complaints, respectively. … Secondary analysis of patient reports of adverse Timeliness, accuracy, communication events ( … The determination of error depends on the temporal or sequential context of events. … Tracking Progress in improving diagnosis: a framework for defining undesirable diagnostic events.

1404. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
      September 01, 2013 - Safety and Adverse Events 3 Introduction and Welcome This enhanced protocol is … from the manufacturer show that less than 1 percent of patients in clinical trials withdrew due to adverse … events. … /denominator of ICU patient days) by 1,000 = total events per 1,000 ICU patient days. … Product Safety and Adverse Events Chlorhexidine (CHG) Risk The risks associated with the use

1405. Final Progress Report: Transforming the Medication Regimen Review Process of High-Risk Drugs Using a Patient-Centered, Telemedicine-Based Approach to Prevent ADEs in the Nursing Home (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/kane-gill-report.pdf
      January 01, 2024 - A recent Office of Inspector General (OIG) report estimated that 37% of all harmful adverse events are … Our prior work confirmed the frequent occurrence of hypoglycemic events in NHs (9.5 events per 1,000 … Post-admission Alerts Evaluated for Adverse Drug Events Telemedicine Communications. … Adverse drug events were defined as injuries resulting from a medication. … drug events in the nursing home.

1406. Scisafetynotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
      June 02, 2025 - . · On average, every patient admitted to an intensive care unit suffers an adverse event. · 44,000 to

1407. Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/unruh-report.pdf
      January 01, 2025 - Composite PSI composite of complications Weighted average of reliability and risk-adjusted rates of adverse … events, such as pressure ulcers, postoperative respiratory failure and postoperative sepsis. … IQIs and PSIs are risk-adjusted hospital rates of mortality and patient safety events obtained from … PSI indicators were rates of adverse events, such as pressure ulcers, postoperative respiratory failure … Licensed nurse staffing and adverse events in hospitals. Med Care 2003 41(1): 142-152.

1408. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
      January 01, 2024 - Solutions for Patient Safety: In 2007, the CERT funded work on identifying Adverse Drug Events using … SPS has reduced falls by 81%, ventilator-associated pneumonias by 47%, adverse drug events by 42%, and … Situation Awareness to Reduce the Rate of UNSAFE Transfers and Serious Safety Events/Evaluating Huddle

1409. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
      January 01, 2024 - drug events (ADEs) that result in injury or death, and the costs of such events are estimated to total … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse outpatient drug events--a problem and an opportunity. N Engl J Med 2003; 348:1587-9. 18. … Impact of basic computerized prescribing on outpatient medication errors and adverse drug events. … Adverse drug events in ambulatory care.

1410. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
      April 14, 2004 - approve consent forms (where applicable), monitor ongoing studies, and investigate reports of alleged adverse … events in approved studies. … Instruments The AAFP PSRS accepted anonymous reports from clinicians, staff, and patients concerning events … For the General Errors study, these could be any type of events, including office process or knowledge … For the Testing Process Errors study, reported events were related only to laboratory tests, diagnostic

1411. Final Progress Report: Automated Medical Interviewing for Diagnostic Decision Support in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
      January 01, 2025 - about the aggregate burden of misdiagnosis-related morbidity, but 47% of diagnostic error-related adverse … events result in serious disability.15 Thus, misdiagnoses represent an enormous source of preventable … Dizziness is the ED symptom most often linked to missed stroke,49 with 35% of cerebrovascular events … Incidence and types of adverse events and negligent care in Utah and Colorado. … The nature of adverse events in hospitalized patients.

1412. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
      June 03, 2021 - Federal agencies are actively developing standardized ways to capture diagnostic safety events to guide … Learning from malpractice claims about negligent, adverse events in primary care in the United States … for National Initiative on Preventing Harm From Diagnostic Error. https://www.leapfroggroup.org/news-events … Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections

1413. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
      June 03, 2021 - Federal agencies are actively developing standardized ways to capture diagnostic safety events to guide … Learning from malpractice claims about negligent, adverse events in primary care in the United States … for National Initiative on Preventing Harm From Diagnostic Error. https://www.leapfroggroup.org/news-events … Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections

1414. Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
      January 01, 2024 - case to hospital leadership of the return on investment of hiring these personnel (i.e., in reducing adverse … drug events and inpatient length of stay). … Medication Reconciliation to Prevent Adverse Drug Events. … Secondary Medication Reconciliation to Prevent Adverse Drug Events 2018. http://www.ihi.org/Topics/ADEsMedicationReconciliation

1415. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
      January 01, 2005 - Systems analysis of adverse drug events. ADE Prevention Study Group. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

1416. AHRQ Safety Program for Surgery: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/safe_surgery_finalreport.pdf
      December 01, 2017 - Recent data from the Medicare Patient Safety Monitoring System found that rates of adverse events did … central line-associated bloodstream infection, ventilator-associated pneumonia) and post-procedural adverse … events (e.g., postoperative venous thromboembolic events) significantly increased. … a program to improve local safety culture did not lead to significant reductions in SSI and other adverse … events were handled; and • Where improvements were needed.

1417. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
      August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … on the Centers for Medicare and Medicaid Services’ list of hospital-acquired complications “never events … communication during nurse transitions, for example: • Reduce the incidence of never events by 5 percent

1418. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
      February 24, 2008 - Introduction Public and professional concern over patient safety, adverse health care events, and medical … Lucian Leape on the causes and prevention of errors and adverse events in health care. … Preventing adverse drug events. Am J Health Syst Pharm 1995; 52: 379-382. 6. Leape LL. … The nature of adverse events in hospitalized patients. … Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.

1419. Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
      January 01, 2014 - 2.1 MILLION 2.1 MILLION From 2010–2014, 17 percent of hospital-acquired conditions (HACs) such as adverse … drug events, healthcare-associated infections, and pressure ulcers have been prevented in hospital

1420. 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