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1561. Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/overview/background/next-steps2.html
      December 01, 2009 - Health care-associated infections are regarded as "never events," that is, adverse events that should

1562. State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
      January 17, 2024 - can lead to inappropriate treatments, disease progression, preventable hospitalizations, and other adverse … Adverse drug events from medication can often mimic acute medical conditions in older adults, thus contributing … and a “prescribing cascade,” where a second, potentially unnecessary drug is prescribed to treat the adverse … Medications (i.e., polypharmacy and deprescribing, medication reconciliation, and adverse medication … Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: a population-based

1563. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
      January 01, 2024 - care facilities during transfers of care may adversely affect the patient’s quality of care, lead to adverse … events, and contribute to the overall cost of the services provided. … and then to the hospital emergency department (ED) can lead to delays in diagnosis and treatment, adverse … events, patient complaints, and increased costs and length of stay.(8-12) The literature suggests that

1564. TeamSTEPPS for Improving Diagnosis Facilitator's Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitators-guide.pdf
      February 04, 2022 - 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. … These events are excellent learning opportunities for team members. … Consequences may include lawsuits, business losses, and adverse media coverage. d. … These events are excellent learning opportunities for team members.

1565. Appendix C. Detailed Descriptions of Agency Research Portfolios | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-c.html
      July 01, 2021 - effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse … drug events, and preventable hospital readmissions ( Agency for Healthcare Research and Quality, 2018 … Safety Organizations program, which enables health care providers to uniformly report patient safety events

1566. Severe Hypertension Scenarios: PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-hypertension-scenarios.pptx
      July 01, 2023 - anesthesiologist Beth, L&D Nurse Frontline SPPC-II SCRIPT  Debriefs should occur after all clinical events … I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … I would like to discuss some of the events surrounding Ms. Smith’s delivery yesterday. … lead to stroke or seizures, she needs to know what treatment options are available to prevent such adverse

1567. Six Building Blocks How-To-Implement Toolkit: Design and Implement Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-design.pdf
      February 18, 2021 - pain is important for several reasons: • Any patient using LtOT, regardless of dose, has a risk of adverse … events, including overdose; • Identifying patients using LtOT provides an opportunity to identify those … dangerous opioid dosages or combinations—such as with sedatives—are putting patients at risk for adverse … events. … dvce=1 https://cmeregistration.hms.harvard.edu/events/identification-counseling-and-treatment-of-oud/

1568. Patient Access to Medical Notes in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/opennotes-1.pdf
      May 01, 2016 - subject to aggressive treatment goals and complex medication regimens, and are at significant risk of adverse … events in ambulatory and primary care.5,6 2 Lack of understanding of how to take medications properly

1569. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
      January 01, 2024 - In addition, the report suggested that there are serious medical errors and adverse patient outcomes … Simulation events were retrieved from the Society for Academic Emergency Medicine (SAEM) simulation

1570. Nursingnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/nursing/nursingnotes.docx
      June 02, 2025 - Slide 22 SAY: Nurse managers should obtain data on quality outcomes and adverse events monthly

1571. Final Progress Report: Risk of Acute Asthma Associated with the Pediatric Use of Opioids (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/chen-report.pdf
      January 01, 2024 - asthma exacerbation in the 12 months prior to the survey.1 Asthma exacerbations are acute episodic events … The mean duration between these historical events indicating uncontrolled asthma and the index analgesic … Given most of these asthma -related events happened on average 5 to 6 months before the index analgesic … Outpatient Opioid Prescriptions for Children and Opioid- Related Adverse Events. Pediatrics.

1572. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
      January 01, 2024 - Scope and Methods: One out of every three adverse drugs events precipitated by a medication error occurs

1573. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
      July 01, 2004 - collaborative patient-physician relationship (e.g., “Make sure your doctor knows about any allergies and adverse … Medications and adverse drug events are a key and often-cited patient safety topic that patient behavior

1574. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
      March 03, 2008 - Introduction Patient falls are the most frequently reported adverse event in hospitals and the leading … responsible for closing the gaps in the defensive barriers and reporting near misses, as well as actual events

1575. Resources for Advanced Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/advanced-practice-guide-brochure.pdf
      March 01, 2016 - families, and health care teams have clear roles and are fully engaged as partners in their care, adverse … events are reduced and health outcomes are better.

1576. Urine Culturing Stewardship in the ICU Setting Facilitator Notes
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing.pptx
      April 01, 2022 - cultures are reported Improve CPOE order sets to require indication “Guidance at point of care” Publicize adverse … events to increase engagement; keep personal Abbreviations: C. diff = Clostridium difficile; CPOE =

1577. Getting Started: Laying the Groundwork for Implementing Automatic Referral and Effective Care Coordination (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-implementation-guide.pdf
      March 01, 2023 - Messaging for a Clinical Manager Clinical Manager CR Benefits -Improving patient health -Reducing adverse … events Evidence of Benefits -CR reduces morbidity and mortality and improves quality of life -CR … implementation Ways to Reduce Barrier/Opposition Generally, CR improves patient health and reduces adverse … events, which are metrics tracked, incentivized by some value-based payers Example: CR reduces the

1578. Overuse of Imaging for the Evaluation of Children with Simple Febrile Seizure: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-192-fullreport.pdf
      November 01, 2019 - Simple febrile seizures are generally felt to be benign events with little to no increased risk of subsequent … 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.

1579. Final Progress Report: Comprehensive Analysis of Data from Testing the Re-engineered Hospital Discharge (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/chetty-report.pdf
      January 01, 2024 - As one may suspect, various factors contribute to a rehospitalization or an adverse event.

1580. Scoring CPCQ (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cpcq-scoring.pdf
      May 01, 2017 - Conclusions: Multiple imputation is a clear leader in accuracy for dealing with missing data, though even in adverse