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Showing results for "adverse events".
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201. AHRQ Strategic Plan for Health System Transformation To Optimize Health, Functional Status, and Well-Being Among Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/priority-populations/publications/aging-well.html
     July 01, 2024 - conditions frequently receive fragmented and sub-optimal care, leading to poor outcomes, including avoidable adverse … events, hospitalizations, and institutionalization, as well as increased costs negatively impacting

202. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - It uses the electronic medical record, or EMR, to make staff aware of residents at risk of adverse events … Slide 6: On-Time Reports for Four Adverse Events Say: There are four sets of On-Time reports to … help prevent four adverse events: pressure ulcers, pressure ulcers that are not healing appropriately … The reports: Focus on preventing adverse events. Are proactive rather than reactive. … Improve root cause analyses when adverse events occur.

203. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - The IOM has called for a reporting system that includes both adverse events and near misses. … A physician- based voluntary reporting system for adverse events and medical errors. … Confidential clinician-reported surveillance of adverse events among medical inpatients. … Adverse drug events in primary care. N Engl J Med. 2003; 348: 1556-1564. 15. … Will, ideas, and execution: Their role in reducing adverse medication events.

204. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - Thus, a subcategory of adverse events ascribed to error or substandard care, called preventable adverse … Few investigators focus on these types of diagnostic adverse events. … Adverse Events, Diagnostic Adverse Events Defined under the Safety Paradigm section above, adverse … Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients.

205. Engage Patients and Families for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
     May 01, 2017 - Slide 16 SAY: Adverse events occur when a patient is harmed as a result of receiving medical care … Medical providers are committed to caring for their patients; however, adverse events can happen. … events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … • Organizations need to engage in strategies to address adverse events.

206. Understanding Omissions of Care in Nursing Homes | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/omissions.html
     October 01, 2019 - Understanding Omissions of Care in Nursing Homes Adverse events and poor health outcomes

207. Return on Investment Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

208. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - Evaluation of perioperative medication errors and adverse drug events. … By addressing common, preventable adverse events, a health care setting can become safer, thereby enhancing … More than three-fourths of PSOs offered analytical support for adverse events, and a similar share … “The Importance of Reporting Safety Events.” 2014. Analytic Support for Adverse Events. … Copyright 2015 ECRI Institute. www.ecri.org • Adverse events • Near misses • Hazards • Common Formats

209. Behavioral Health AI Free Text Analysis - NPSD Data Spotlight (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/npsd-spotlight_behavioral-health.pdf
     September 01, 2025 - advice about discharge can have an increased risk of medical problems, including falls and other adverse … among medical inpatients than in the general population.2,3 Common BH-related issues or adverse … Adverse events occurring on mental health units. General Hospital Psychiatry. 2018. … Predictors of prolonged length of stay and adverse events among older adults with behavioral health-related … Evidence-based interventions to reduce adverse events in hospitals: A systematic review of systematic

210. Appendix A. Recommendations for Ideal Consumer Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendixa.pdf
     June 02, 2025 - RTI) and Consumers Advancing Patient Safety, Designing Consumer Reporting Systems for Patient Safety Events … for an ideal reporting system that consumers could use to report experiences with patient safety events … The system should collect information on all types of events, ranging from near-miss and no-harm events … to adverse events. … health care and whose members, employees, or affiliate entities may be the subjects of reports about adverse

211. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - event. 1.5% experienced harm that contributed to death. 44% of adverse events were preventable. … event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … Potential decrease in adverse events being litigated, which can lead potentially led to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … events really hinges on knowing about them immediately.

212. Section 7C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
     June 02, 2025 - Table VII.C.1 – Distribution of insurance types and adverse … events across sites based on GAPPS study analytic sample (n = 3,151) Insurance n (%) AE rate P-Value … 58.2%) 0.10 <0.001 No Insurance 102 (3.2%) 0.04 0.001 Table VII.C.2 – Analysis of differences in adverse

213. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. 8 Develop a Measurement Strategy5 WHAT to measure Process … events.”

214. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

215. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
     February 01, 2017 - Slide 11: Safety 3 No serious adverse events. … Slide 14: Adverse Events 4 9 patients had 14 adverse event (<1% of activities): Falls to knees … No documented adverse events. 6. Clark DE, Lowman JD, Griffin RL, et al. … Slide 26: Conclusions—Safety Adverse events ranged from agitation to transient physiological events … Adverse events ranged from 2.3 to 8.7 per 100 patients. 3-5 3.

216. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - as from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.

217. Table 7.A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
     June 02, 2025 - Table VII.A.1 – Distribution of race/ethnicity and adverse … events across sites based on GAPPS study analytic sample (n = 2,834) Race/Ethnicity n (%) AE rate … Hispanic 352 (12.4%) 0.18 <0.001 Other 161 (5.7%) 0.12 0.12 Table VII.A.2 – Analysis of differences in adverse

218. AHRQ's Patient Safety Culture Survey Used to Set Baselines for Improvements at Chicago Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0609.html
     October 01, 2014 - Importantly, the survey also highlighted that staff were more uncomfortable with filing reports of adverse … events than was previously recognized. … team targeted its initiatives to address three specific dimensions of patient safety: reporting of adverse … events, handoffs and communication, and feedback and awareness of adverse events.

219. Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

220. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
     July 01, 2023 - Expanding the scope to also include “problems” encourages reporting of adverse events where patients … Given the uncertainties inherent in diagnosis, a portion of adverse diagnostic events that are not always … The literature on medical errors documents that the long-term harms associated with adverse events are … First, when patients experience adverse medical events, they frequently switch to alternative venues … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review