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Showing results for "adverse events".
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1721. Final Progress Report: A Formal Approach to Detecting and Correcting Simultaneous Masking in the IEC 60601-1-8 International Medical Alarm Standard (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/bolton-report.pdf
      January 01, 2024 - time was explicitly represented by a clock and simulation steps had to account for the number of time events … states, the model computes a set of T discrete times based on the total number of times when change events … probability that medical practitioners will hear the alarms, respond to them appropriately, and thus avoid adverse

1722. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weinger-report.pdf
      January 01, 2024 - Study Rationale Communication failures continue to be the most frequently cited “root cause” of adverse … events reported to The Joint Commission (personal communication, Margaret VanAmringe, February 2, … accurately and consistently portray the clinical role and also respond appropriately to unexpected turns of events

1723. Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-rural-healthcare.pdf
      July 01, 2024 - these errors contribute to approximately 10 percent of patient deaths and 6-17 percent of hospital adverse … events.4 The National Academy of Medicine (NAM) defines diagnostic errors as the failure to establish … Serious misdiagnosis-related harms in malpractice claims: the “Big Three”–vascular events, infections

1724. Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions, Version 2: Evaluation Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ecareplan/reports/ecare-plan-for-mcc-v2.pdf
      January 01, 2025 - and behavioral health conditions, require ongoing management to improve health outcomes and avoid adverse … events. … and behavioral health conditions, require ongoing management to improve health outcomes and avoid adverse … events. … Also integral to this process are HL7 Connectathons, hands-on events for developers and implementers

1725. Technical Review 17: Nutritional Research Series, Vol. 1: Application of Systematic Review Methodology to the Field of Nutrition (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp1.pdf
      January 01, 2009 - constituents and heath outcomes Dose-response of soy forms or constitutions Frequency and type of adverse … acids Other Plasma Phospholipid fatty acids Platelet fatty acids Adipose tissue fatty acids Adverse … Events (n-3) Fatty Acid Consumption Source, Dosage, Duration Modifiers Drug Interactions Others

1726. 3. Assessment Plan and Methodology | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen3.html
      April 01, 2018 - achieve its intended (positive) impact without additionally causing (negative) unintended effects or adverse … Prevailing conditions and events occurring in the external environment that could affect the implementation

1727. Final Progress Report: Advancing Quality Measurement and Care Improvement with Health Information Exchange (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/shapiro-report.pdf
      January 01, 2025 - The association between emergency department crowding and adverse cardiovascular outcomes in patients

1728. Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
      February 01, 2005 - Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments 469 Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments Elizabeth A. P. Vane, Edward Drost, Daryl Elder, Yvonne Heib Abstract The United States Army per…

1729. Appendix D. Site Visit Process Comparison | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html
      April 01, 2018 - Intake information collected: antibiotics taken, previous anesthesia experiences, allergies, recent events

1730. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
      May 01, 2024 - But they can also lead to inefficiencies, cognitive overload, and safety events.64 Understanding the … Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event

1731. Multiple Chronic Conditions Chartbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf
      April 01, 2014 - NO 993 EFFECTS OF AIR PRESSURE -3 NO -4 NO 994 EFFECT EXTERNAL CAUS NEC -4 NO -4 NO 995 CERTAIN ADVERSE

1732. Final Progress Report: Optimizing safety of mother and neonate in a mixed methods learning laboratory (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/halamek-report.pdf
      January 01, 2025 - wore an eye tracking system to record their gaze pattern and fixation, and all treatment decision events … Measures for treatment decision events included time to a) adjust the FiO2 to achieve goal SpO2, b) … familiarity with the display and thereby reduced the need for training; and archived critical time events

1733. Final Progress Report: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/peterson-report.pdf
      January 01, 2025 - Because this is a more aggressive decolonization regimen with potential adverse events from the systemic

1734. Final Progress Report: Exploratory Study Using Queuing Theory To Improve Nurse Staffing Effectiveness (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/stone-report.pdf
      January 01, 2024 - relate higher levels of nurse staffing (both in quantity and level of preparation) to lower rates of adverse … Additionally, the interventions were categorized as either scheduled or unscheduled events.

1735. Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsicompanion.pdf
      October 18, 2012 - 26.6% 22.8% 0.760 24.9% 24.6% 0.749 3 Systematic analysis and proactive learning from harmful events … or events with potential harm as raised by front-line staff (other than M&Ms and official RCA) 52.3% … Published before 2002 Engemann JJ, 2003 Adverse clinical and economic outcomes attributable to methicillin

1736. Final Progress Report: Safe delivery of primary care to vulnerable populations: Using simulation to assess team performance in responding to behavioral and social determinants of health (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/zabar-report.pdf
      January 01, 2024 - Errors of omission are almost impossible to detect unless they can be traced to an adverse event.

1737. Mod6-Care-For-Caregiver-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/mod6-care-for-caregiver-guide.pdf
      April 01, 2016 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse

1738. Final Progress Report: Cardiovascular Care Disparities: Safety-Net HIT Strategy (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/ferguson-report.pdf
      January 01, 2024 - the stakeholders – providers, administrators, and patients – are not encumbered by moral hazard and adverse

1739. Chartbook on Healthy Living: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
      April 01, 2018 - Good medical practice includes asking patients about all their medications which can prevent adverse … events. 27 The Food and Drug Administration and others urge patients to tell health care providers … New frontiers in patient-reported outcomes: adverse event reporting, comparative effectiveness, and quality … Weight loss is associated with adverse, costly clinical outcomes, including increased hospitalization

1740. Final Progress Report: AUA 2022 Quality Improvement Summit: Opportunities to Improve Care in Urology (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/gore-report.pdf
      January 01, 2024 - Delivering bad news is like performing an invasive procedure; both are life-changing events for the … personal responsibility, a focus on the cure at the expense of quality of life, and a perception of adverse … events as personal failures can all interfere with a patient-centered approach.46 Dr.