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1581. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
      June 15, 2003 - Every hospital used an internal standard for tracking these events, and methods varied. … Reporting of adverse events. N Engl J Med 2003 Nov;347(20):1633–8. 12. Burke JP.

1582. Module 2. Communicating Change in a Resident's Condition | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod2.html
      October 01, 2014 - When procedures for team communication are in place, the number of "adverse events" (negative effects … three main components are to: Gain knowledge and skills to understand systems of care and minimize adverse

1583. Final Progress Report: A Memory-Based Approach to Reducing Medication Errors (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/kazi-report.pdf
      January 01, 2024 - PM failure is likely to have adverse patient safety implications because of heightened risk of medication

1584. Faclearncusp (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/faclearncusp.docx
      January 01, 2009 - It provides a comprehensive process to investigate harmful events or patient safety concerns and determine

1585. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship-references.html
      August 01, 2024 - Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events.

1586. Final Progress Report: Emergency Department Overcrowding and Quality of Acute Asthma Care for Children (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/sills-report.pdf
      January 01, 2024 - Objectives 2.4 – 2.5 Given that studies in adults hospitals have found increases in sentinel events … finding that more than 20% of hospital midnights were above 85% occupancy raises serious concerns about adverse

1587. Best Practices in the Diagnosis and Treatment of Cellulitis and Skin and Soft Tissue Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/cellulitis-facilitator-guide.pdf
      November 01, 2019 - However, trim/sulfa was associated with adverse events in approximately 10 percent of patients.

1588. Facilitator Guide: Overview of the Improvement Model (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
      December 01, 2017 - readmissions, and deaths are inevitable—our patients are old, our patients are sick—yet at least half of these adverse … surgical events are preventable, and they take an immeasurable toll on our patients and their families … overall patient safety grade and then also ask your clinicians and staff to comment on the number of events

1589. Program Overview: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-fac-notes.html
      December 01, 2017 - readmissions, and deaths are inevitable—our patients are old, our patients are sick—yet at least half of these adverse … surgical events are preventable, and they take an immeasurable toll on our patients and their families … overall patient safety grade and then also ask your clinicians and staff to comment on the number of events

1590. CUSP Toolkit, The Role of the Nurse Manager, Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/nursing/nursing-notes.html
      December 01, 2012 - Quality/Safety Say: Nurse managers should obtain data on quality outcomes and adverse events monthly

1591. Final Progress Report: Are Volume Standards Accurate Measures? (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
      January 01, 2024 - the AHRQ Patient Safety Indicators, there are significant differences in the risk-adjusted rates of adverse … events depending on whether the POA indicator is used to distinguish between pre- existing conditions … The use of the POA indicator will increase the accuracy of the AHRQ PSIs as measures of adverse outcomes

1592. Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/iomracereport/reldatasum.html
      October 01, 2018 - increased probability of receiving unnecessary diagnostic tests ( Hampers et al., 1999 ), more serious adverse … Language proficiency and adverse events in US hospitals: A pilot study.

1593. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - computerized provider order entry, CPOE) has been touted as a key method to reduce medication errors and adverse … drug events. … nursing staff not recognizing premedications that were indicated but not ordered based upon previous adverse

1594. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf
      January 01, 2014 - staff-level performance improvement team brainstorming various strategies, testing them (e.g., through kaizen events … the American College of Cardiology/American Heart Association guidelines for management and increased adverse … events.

1595. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
      September 01, 2015 - asymptomatic bacteriuria can lead to antimicrobial resistance, Clostridium difficile infection, and adverse … drug events. … Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events

1596. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
      September 01, 2015 - asymptomatic bacteriuria can lead to antimicrobial resistance, Clostridium difficile infection, and adverse … drug events. … Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events

1597. 3. Breadth and Focus Areas of Federal Agency Research Portfolios in HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.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 … the provision of a treatment as appropriate), as well as both intermediate (e.g., disease control, adverse … patient safety events, patient experience) and definitive outcomes of care (e.g., quality of life, mortality

1598. Dissemination Planning Tool: Exhibit A from Volume 4 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances/planning.html
      July 01, 2022 - What recent or future events might help or hinder end user interest in your finding or product? … What recent/future events might help or hinder their willingness to work with you?

1599. Methods (continued, 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
      July 01, 2018 - Motivators of Organizational Change Organizational motivators are systems, events, or environmental … Changes in reimbursement that incorporate payment penalties for events or conditions that should not … to a person or persons, not related to the natural course of the patient's illness." 102 Sentinel events … patients on an organizational level (e.g., on PFACs and decisionmaking committees). 103,104 Sentinel events … example discussed above, DFCI received both regional and national media attention after its sentinel events

1600. Adolescent Depression Remission/Response (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-247-fullreport.pdf
      December 01, 2019 - treatment goals and outcomes, including assessing depressive symptoms and function, monitoring for adverse … events during antidepressant treatment, and reassessing diagnosis and treatment if no improvement is … in Primary Care (GLAD-PC) recommends systematic assessment of symptoms and function, monitoring for adverse … events during antidepressant treatment, and reassessing diagnosis and treatment if no improvement is