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Showing results for "adverse events".
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1741. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
      April 03, 2008 - care delivery process, especially from small mistakes and problems, rather than from consequential adverse … events, are rare.”1 The timely review and rating of close calls can provide valuable diagnostic information … Sensemaking also assists in categorizing and prioritizing the risk knowledge that comes from reported events … Reduction of adverse drug events and medication errors in a community hospital setting.

1742. AHRQ Safety Program for Ambulatory Surgery Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/ambulatory-surgery-report.pdf
      May 01, 2017 - 8 Since the beginning of the program, participating facilities have reported very low rates of adverse … Interestingly, the QIAs reported greater stakeholder involvement in facilities that experienced a recent adverse … Lack of Feedback Loop and Data Reporting to ASCs When Adverse Events Occur. … Obtaining a true picture of the adverse events proved difficult as patients do not typically return … Data reporting varies in ASCs on how adverse events are communicated after the initial procedure/surgery

1743. Designing Consumer Reporting Systems for Patient Safety Events: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/reporting/11-0060-EF.pdf
      May 01, 2011 - to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse … to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse … events

1744. Designing Consumer Reporting Systems for Patient Safety Events: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/11-0060-EF.pdf
      May 01, 2011 - to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse … to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse … events

1745. Chapter 3. Regulatory Requirements | Agency for Healthcare Research and Quality
      www.ahrq.gov/funding/policies/informedconsent/ictoolkit3.html
      November 01, 2015 - The AHRQ Informed Consent and Authorization Toolkit for Minimal Risk Research Chapter 3. Regulatory Requirements Previous Page Next Page Table of Contents The AHRQ Informed Consent and Authorization Toolkit for Minimal Risk Research Chapter 1. Background Chapter 2. How To Improve Informed Consen…

1746. Best Practices in the Diagnosis and Treatment of Cellulitis and Skin and Soft Tissue Abscesses – Slides (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/skin-soft-tissue-guide.docx
      September 01, 2022 - how that informs empiric therapy · Identify empiric antibiotic regimens for cellulitis that minimize adverse … events · Discuss duration of antibiotic therapy for cellulitis and · Discuss the expected time course … These adverse events are more common with prolonged durations of therapy, underscoring the importance

1747. Strategy 3: Bedside Shift Report (Tool 3)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
      July 23, 2010 - For example, one study found that more than 70 percent of adverse events are caused by breakdowns in … As noted above, one study found that more than 70 percent of adverse events are caused by breakdowns … infections, and air embolism, all of which are on CMS’s list of hospital-acquired complications “never events … successful transfer of information between nurses going off duty and nurses coming on duty to prevent adverse … events and medical errors.

1748. Strategies for Improving Patient Safety in Small Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Tupper_73.pdf
      March 20, 2008 - size and lower census in rural hospitals means that they do not experience a sufficient volume of events … ) that enables the user to quickly check drug information, such as dosing, drug-drug interactions, adverse … practice efficiency and provider knowledge, improved drug- related decisionmaking, and prevention of adverse … drug events.11 Immediate access to necessary 8 drug information was reported as a key benefit … Protocols become even more necessary at small facilities with low frequency of certain clinical events

1749. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=71
      January 01, 2024 - perioperative mortality and morbidity, 5-year survival, and the identification of factors associated with adverse … Keywords: Cardiovascular Conditions, Surgery, Adverse Events Chen C , Winterstein AG , Lo-Ciganic … Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events

1750. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=275
      January 01, 2024 - asserts that shorter courses are better due to reduced exposure which intrinsically reduces the risk of adverse … events and of selective pressure that drives resistance in our microbiomes. … Keywords: Blood Clots, Surgery, Emergency Department, Adverse Events, Prevention, Patient Safety

1751. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=430
      January 01, 2024 - Keywords: Healthcare Cost and Utilization Project (HCUP), Surgery, Patient Safety, Adverse Events … Keywords: Adverse Drug Events (ADE), Diabetes, Medication, Cancer: Prostate Cancer, Risk Yun

1752. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
      April 18, 2004 - Advances in Patient Safety: Vol. 1 80 Introduction Patients face a significant risk of adverse events … data Unscheduled readmission within 30 days of discharge was chosen as an indicator of a potential adverse … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Adverse events due to discontinuations in drug use and dose changes in patients transferred between … Preventable and non- preventable risk factors for adverse drug events related to hospital admission

1753. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=132
      January 01, 2024 - Sites used the Institute for Healthcare Improvement’s definition in defining an adverse event and a modified … They reviewed a total of 4735 cases and identified 381 events, of which 287 were near-misses, and 94 … had adverse events (AEs). … Quality concern rate (events without harms) was 6.06% (5.42-6.78%). … They found that intraoperative hand-offs were frequent and not well coordinated with intraoperative events

1754. Redesigning Systems To Improve Teamwork and Quality for Hospitalized Patients: RESET Project Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reset-guide.pdf
      January 01, 2020 - Project teams should assess adverse events, patient experience and efficiency outcomes. … • Adverse events. … The project team should determine what types of adverse events are being collected and work to create … These reports should evaluate rates of adverse events before, during and after implementation of the … Impact of regionalized care on concordance of plan and preventable adverse events on general medicine

1755. SOPS™ Health Information Technology (Health IT) Supplemental Items for Hospitals Webcast Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-transcript.pdf
      July 25, 2018 - HAIs are a particularly important topic for us, as are all patient safety events and event types. … First, by preventing errors and adverse events. … And third, tracking and providing feedback about adverse events. … There's many ways we think about that prevention of errors piece, which was in the first bullet in adverse … events using IT.

1756. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=481
      January 01, 2024 - researchers conducted a two-phase study to understand whether patients and families who have experienced an adverse … Keywords: Adverse Events, Medical Liability, Patient and Family Engagement, Patient Safety Hsuan

1757. Final Progress Report: The PeaceHealth Community-wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/stock-easton-report.pdf
      January 01, 2024 - drug events are as frequent, or more frequent, in the ambulatory setting. … events. … events in the clinic, Emergency Dept (ED), and hospital. … Does a shared electronic med list reduce med errors and adverse drug events? … events by participating in this model of care.

1758. Use of Copper-Infused Surfaces Reduces Clostridioides difficile Spores | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/948.html
      March 01, 2025 - recommends that women wait more than 6 months after a live birth before getting pregnant to prevent adverse

1759. Final Progress Report: Proactive Risk Assessment in the ED: Building the Safety Case (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/wears-perry-report.pdf
      January 01, 2025 - Many adverse events in healthcare are low-frequency but high-impact episodes with multiple contributors … Therefore, traditional biomedical approaches to understanding and modeling these events, with their … Fault and event trees were created to represent the pathways by which undesired events might arise … The range for the frequencies of scenarios in terms of events per unit time was: 1/shift – 1/day – … argument, updated periodically as new information becomes available (for example, after a near miss or adverse

1760. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=456
      January 01, 2024 - Keywords: Adverse Events, Heart Disease and Health, Medical Devices, Patient-Centered Outcomes Research … Keywords: Surgery, Health Information Technology (HIT), Adverse Events, Patient Experience, Hospital … technology use & implementation, and identified a framework for understanding & overcoming unintended adverse