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1481. Appendix F. Interventions | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/appf.html
      March 01, 2017 - Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool … Reducing the risk of adverse drug events in older adults (Pretorius, Am Fam Physician, 2013, PMID 23547549 … potentially inappropriate prescriptions and screening tool to alert doctors to the right treatment reduced adverse … events in elderly patients.

1482. Final Progress Report: Optimal Prevention of Hospital-Acquired Venous Thromboembolism (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/maynard-report.pdf
      January 01, 2024 - Our long-term objective was to optimize prevention of hospital-acquired venous thromboembolic events … The associated cost of these events, in morbidity, mortality, and patient care dollars, is immense. … A substantial proportion of these events are hospital acquired [1] and constitute an unacceptable risk … This recommendation was based on overwhelming evidence that thromboprophylaxis reduces adverse patient

1483. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-team-assessment-scale-jtcommjqualpatsaf.pdf
      June 30, 2024 - work as an effective team. 4 According to The Joint Commis- sion, one of the most reviewed sentinel events … Team members use daily/weekly huddles and briefs to stay informed, address issues, share unexpected events … communication practices to identify opportunities for improvement (for example, this survey tool, debriefing events … Team members have a systematic process in place to capture and learn from near misses and no-harm adverse … events that occur because of communication gaps

1484. 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

1485. 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

1486. 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

1487. 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?

1488. 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

1489. Final Progress Report: National Trends in Outpatient Quality Indicators (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/stafford-fortmann-report.pdf
      January 01, 2024 - Among barriers to guideline adherence are upper gastrointestinal events, drug marketing campaigns that … We examined trends in COX-2 inhibitor use based on risk for adverse events from NSAIDs. … Among patients with the lowest risk for adverse events from NSAIDs, the proportion receiving a COX-2

1490. Is Your Organization Ready for TeamSTEPPS™? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
      August 01, 2005 - Objective information can originate from a variety of sources, including adverse event and near-miss

1491. Reinforcing the Value and Roles of Nurses in Diagnostic Safety - Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
      September 02, 2022 - Discuss the associated tasks and thought processes taking place during those events. 4 Domain 3: … SBAR),27-30 to structure communication with physicians and other diagnostic team members and reduce adverse … events. … in their day-to-day operations. 7 e Any safety events or “good catches” identified from these … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events. July 2022.

1492. 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

1493. 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

1494. Technical Specifications and Chart Abstraction Tool (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-tech-specs.pdf
      December 14, 2011 - 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse

1495. 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.

1496. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool5.html
      March 01, 2025 - Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse

1497. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
      March 01, 2025 - Pay special attention to medicines for which the adverse consequences of taking them incorrectly are … Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse

1498. 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

1499. 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.

1500. 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