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1641. Rapid Response for Perinatal Safety: Rapid Response Systems | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/tool-rapid-response-systems.html
      July 01, 2023 - Patients on perinatal units can experience cardiopulmonary and metabolic events or deterioration that … Learn From Defects (CUSP Module) Debrief and analyze near misses and adverse events, regardless … Unit can decide its approach to debriefing events based on seriousness of event, expertise available, … Have a process in place to review severe maternal or neonatal morbidity and mortality events, regardless

1642. Manage-Resident-Uti-Facilitator-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-UTI-facilitator-guide.docx
      June 01, 2021 - We have learned that unnecessary antibiotics needlessly put individual residents at risk for adverse … This is a good choice with a relatively low adverse event profile. … Health-care practitioners should use the Learning From Antibiotic Adverse Events form and be encouraged

1643. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=185
      January 01, 2024 - Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Patient Safety, Central Line-Associated … Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse … Events Vu JV , Gunaseelan V , Dimick JB Mechanisms of age and race differences in receiving … Transitions of Care Yang AD , Quinn CM , Hewitt DB National evaluation of needlestick events … National evaluation of needlestick events and reporting among surgical residents.

1644. National Action Alliance to Advance Patient Safety Webinar Series (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
      August 22, 2023 - The board’s tracking of adverse events and delineated types of errors (including near misses) - focus … ensure they have/are part of QAPI efforts where appropriate and understand how to identify and report events … complaints in cardiology and cardiac surgery • Patient mortality triple the norm and rise in adverse … events and claims (often lagging indicators) • Patient complaints • Culture of Non- transparency … • Could a department hide embarrassing events from management and the board?

1645. Session 1 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
      October 01, 2014 - When things go wrong (adverse events) or look as if they are about to (near-misses), we may feel embarrassed … Everyone—residents and staff—does better when people support discussion and learn from near misses and adverse … events.

1646. Applying the AHRQ Pediatric Quality Indicators to Hospital Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b1_pdi_applyingpdis.pdf
      March 01, 2016 - Expected rate = Expected events/Eligible population Risk-adjusted rate = (Observed events/Expected … = for each PDI, the total sum of events that occurred in the eligible population for that specific … indicator Expected events = for each PDI, the total sum of events expected to occur for that specific … The expected probabilities for the set of discharges are summed to obtain the number of expected events … (Note that a lower rate for a PDI signifies better performance because fewer adverse events have occurred

1647. Applying the AHRQ Quality Indicators to Hospital Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
      March 01, 2016 - Expected rate = Expected events/Eligible population Risk-adjusted rate = (Observed events/Expected … = for each QI indicator, the total sum of events that occurred in the eligible population for that … specific indicator Expected events = for each QI indicator, the total sum of events expected to occur … The expected probabilities for the set of discharges are summed to obtain the number of expected events … (Note that a lower rate for a PSI signifies better performance because fewer adverse events have occurred

1648. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=32
      January 01, 2024 - microbial were observed in those reaching the first decompensation, compared with subsequent decompensating events … Ten percent experienced adverse drug events because of outpatient medication errors. … Keywords: Children/Adolescents, Cancer, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Ambulatory … There was also an improvement on alignment of sources of payments between donor and recipient events

1649. AHRQ Celebrates Patient Safety Awareness Week | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/755.html
      March 01, 2021 - Association between parent comfort with English and adverse events among hospitalized children.

1650. Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-transcript.html
      January 01, 2017 - She leads the analytics of all serious adverse events, and her current project schedule includes improving … alarm safety, TeamSTEPPS, peer support learning following adverse events, and participation in the North … There are also two outcome items, Patient Safety Grade and Number of Events Reported in the Past 12 Months … that we might search for policies related to, like corrective action, our sentinel event policy, our adverse … It helps us to improve our offerings and plan future events that meet your needs.

1651. Just Culture Webcast November 2016 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
      June 01, 2017 - She leads the analytics of all serious adverse events, and her current project schedule includes improving … alarm safety, TeamSTEPPS, peer support learning following adverse events, and participation in the … There are also two outcome items, Patient Safety Grade and Number of Events Reported in the Past 12 Months … that we might search for policies related to, like corrective action, our sentinel event policy, our adverse … It helps us to improve our offerings and plan future events that meet your needs.

1652. Gap Analysis Facilitator's Guide: Appendix A | Agency for Healthcare Research and Quality
      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

1653. Chapter 1. Environmental Scan | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program1.html
      April 01, 2018 - The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes … These events include "errors," "deviations," and "accidents.” … meta-definition to establish the final definition below: Patient safety is the prevention and amelioration of adverse

1654. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
      April 04, 2008 - stakeholders (including patients and families) and has the potential to enhance the understanding of events … WHO draft guidelines for adverse event reporting and learning systems. … patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse … events. … Rates and types of events reported to establish incident reporting systems in two U.S. hospitals.

1655. Final Progress Report: Pharmacist Technology for Nursing Home Resident Safety (pdf file)
      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.

1656. The “Never Antibiotics” Diagnoses: ​Viral Acute Upper Respiratory Infection: ​the Common Cold – Facilitator Guide (doc file)
      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

1657. Morning Briefing and Shadowing (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing.html
      April 01, 2013 - And were there any adverse events that we need to know of? … And you know with the Learning From Defects tool, we really like to walk through the adverse events as … It was our medical students that first identified the number of adverse events or defects that they identified … events. … study where I read over 3,000 adverse events, and what I noticed was that not only did the resident

1658. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
      January 01, 2017 - solving addresses future needs and improves overall patient safety culture Where To Find Defects Adverse … event reporting systems Sentinel events Claims data Infection rates Complications Staff Safety Assessments

1659. Patient Safety and Quality Areas | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/about/areas.html
      February 01, 2018 - Team Training Falls Pressure Ulcers Diagnostic Safety Blood Clot Prevention and Treatment Adverse … Drug Events AHRQ Quality Indicators (QIs)

1660. From Quality Measures to Quality Care: Examples of Quality Improvement at Work | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/quality-measures/21st-century/challenges.html
      June 01, 2018 - Preventing Adverse Drug Reactions Preventable adverse drug events cause significant mortality each … drug events. … LDS Hospital in Salt Lake City, Utah, has taken steps to improve its rate of adverse drug events. … drug events in its cardiac monitoring unit in 1 year ( Leape, 1998 ). … Event Policy, which encourages accredited health care organizations to voluntarily report unexpected events