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www.ahrq.gov/funding/policies/informedconsent/icform2.html
September 01, 2009 - withdrawal from the research study, to conduct investigations of scientific misconduct, or to report adverse … events.]
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www.ahrq.gov/patient-safety/reports/engage/intro.html
March 01, 2017 - Practices to improve patient safety thus include those that reduce the occurrence of preventable adverse … events. 17
Patient Engagement: "a set of behaviors by patients, family members, and health professionals
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www.ahrq.gov/teamstepps/instructor/essentials/implguide1.html
November 01, 2018 - You may start by doing simple counts of your target events or clinical outcomes and displaying these … Rates are calculated by dividing the number of events that did occur by the total number of opportunities … Prophylactic Antibiotic Administration
Number of patients admitted to labor & delivery who incurred an adverse … event or near miss / Total number of patients admitted to labor & delivery = Rate of Labor & Delivery Adverse … & Near-Miss Events
Number of live-born full-term neonates with birth trauma (injury) / Total number
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www.ahrq.gov/news/newsletters/e-newsletter/913.html
May 01, 2024 - Application of trigger tools for detecting adverse drug events in older people: a systematic review and … Medication safety event reporting: factors that contribute to safety events during times of organizational
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/23072-Stifter-draft-1.pdf
March 02, 2015 - Scope : There is little research demonstrating the influence of nurse continuity in preventing adverse … Never events
(adverse events affecting patients during hospitalization that are serious and largely … Patient safety network patient safety primers: Never events. … The effects of nurse staffing on adverse
events, morbidity, mortality, and medical costs. … Following the trail: Connecting unit characteristics with
never events.
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www.ahrq.gov/sites/default/files/2024-01/stifter-report.pdf
January 01, 2024 - Scope : There is little research demonstrating the influence of nurse continuity in preventing adverse … Never events
(adverse events affecting patients during hospitalization that are serious and largely … Patient safety network patient safety primers: Never events. … The effects of nurse staffing on adverse
events, morbidity, mortality, and medical costs. … Following the trail: Connecting unit characteristics with
never events.
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www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
January 01, 2024 - Effectively responding when error occurs, and engaging patients in organizational
learning from such events … Effectively responding when error occurs, and engaging patients in organizational
learning from such events … However, these earlier events focused more on articulating mission and goals and
achieving the pledge … meaningful best practice for response after error throughout Metropolitan
Chicago for responding to an adverse … meaningful best practice for response after error throughout
metropolitan Chicago for responding to an adverse
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Layde_34.pdf
March 14, 2008 - systems that
monitor the occurrence of medical errors, an approach that focuses on medical injuries or
adverse … events that occur from medical care may be more reliable, engender less defensiveness,
and promote … The nature of
adverse events in hospitalized patients. … Perioperative cardiac events:
• Cardiac event during a procedure (997.1) or
• Myocardial infarction … Poisoning by anticoagulants (964.2) or,
• Accidental poisoning agents affecting blood (E858.2) or
• Adverse
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www.ahrq.gov/research/findings/studies/index.html?page=320
January 01, 2024 - Keywords: Adverse Drug Events (ADE), Children/Adolescents, Disabilities, Medication, Patient Safety … Meaningful use of health information technology and declines in in-hospital adverse drug events. … Keywords: Health Information Technology (HIT), Electronic Health Records (EHRs), Adverse Drug Events … Keywords: Medication, Guidelines, Diabetes, Adverse Drug Events (ADE)
Chandakkar PS , Venkatesan … Keywords: Adverse Drug Events (ADE), Diabetes, Medication, Risk
Loucas CA , Brand SR , Bedoya
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/nurses.html
August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … This video demonstrates an example of emotional support provided for the nurse caregiver after an adverse
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … This video demonstrates an example of emotional support provided for the physician caregiver after an adverse
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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-Graham_77.pdf
March 05, 2008 - An observational study showed that herbal
supplements are associated with adverse events of all levels … Adverse Drug Events Among Herbal and Dietary Supplement Users
Twenty-nine (29 percent) of the 101 HDS … Adverse events
associated with dietary supplements: An observational
study. … Adverse drug
events in ambulatory care. N Engl J Med 2003; 348:
1556-1564.
15. … Incidence of
adverse drug events and potential adverse drug events.
Implications for prevention.
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
August 01, 2022 - clinician attitudes about the disclosure of individual, team, and system failures associated with four adverse … members tended to agree on which system failures were important to disclose, regardless of the type of adverse … Clinician responses were more varied and were affected by type of adverse event, but they did agree with … events, and conducting clinical safety interventions. … transitioning from hospital to home care to determine the potential for discrepancies to result in an adverse
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www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/findings.html
May 01, 2016 - clinician attitudes about the disclosure of individual, team, and system failures associated with four adverse … members tended to agree on which system failures were important to disclose, regardless of the type of adverse … Clinician responses were more varied and were affected by type of adverse event, but they did agree with … events, and conducting clinical safety interventions. … transitioning from hospital to home care to determine the potential for discrepancies to result in an adverse
-
www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
January 01, 2024 - Heightened awareness of adverse drug events may have occurred in
the intervention homes. … Trends in decreases in hospitalizations due to serious adverse events were observed
but did not reach … The prevention of adverse drug events. ECPN 2005;June:26-32.
Feinberg JL. … Incidence and preventability of adverse drug events in
nursing homes. … A computer alert system to prevent injury from adverse
drug events. JAMA 1998; 280: 1317-1320.
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www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - The Standard for “Never Events”
There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”
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www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
January 01, 2024 - safety events. … safety events. … Rates of Adverse Safety Events by
BMI Category
Fa
lls
Fa
lls
w
ith
in
ju
rie
s
Pr
es
su
re … In fact, across the adverse safety events, we found that obesity was
actually a protective factor for … Thus, it
was unexpected that for-profit NHs had lower adverse events among their residents with
obesity
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/11835-Lapane-draft-1.pdf
January 01, 2006 - Heightened awareness of adverse drug events may have occurred in
the intervention homes. … Trends in decreases in hospitalizations due to serious adverse events were observed
but did not reach … The prevention of adverse drug events. ECPN 2005;June:26-32.
Feinberg JL. … Incidence and preventability of adverse drug events in
nursing homes. … A computer alert system to prevent injury from adverse
drug events. JAMA 1998; 280: 1317-1320.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/common-cold-guide.docx
September 01, 2022 - Harm associated with antibiotics includes adverse drug events, microbiome disruption, and antibiotic … Adverse drug events from antibiotics are very common. … Patients are four times as likely to require an emergency department visit for an adverse event related … events from the medications should be taken into consideration before recommending them to individual … In fact, they could lead to an adverse event, like diarrhea, that could make it harder to participate
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - management
Disruptive behavior and/or code of conduct
Investigation of occurrences (i.e., sentinel events … Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse … or "harm" events
___
___
Organizational safety and/or quality plan
FMEAs