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Showing results for "adverse events".
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221. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Meliones MD, MS Abstract Background: During the analyses of adverse events, a commonly described … These patients are at increased risk for adverse events because of the complexity of their diagnosis … Understanding adverse events: Human factors. Qual Health Care 1995; 4: 80-89. 5. Reason J. … The nature of adverse events in hospitalized patients. … Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051-1056. 16.

222. Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/neonatal-interfacility-transfers-long-desc.html
     January 01, 2025 - events occur in up to 70 percent of pediatric critical care ambulance transports, even if performed … Human factors are the root cause of 67 percent of avoidable adverse events in transport due to communication … events. … Neonatal transport safety metrics and adverse event reporting: a systematic review . … Neonatal transport safety metrics and adverse event reporting: a systematic review .

223. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - mindful of its limitations for a given purpose. 40 For instance, many routinely recorded discrete events … communication differences, will also need to be addressed to make the most of such efforts. 59,61,62 Real-time adverse … records is through the “trigger” approach, which aims to “alert patient safety personnel to possible adverse … events so they can review the medical record to determine if an actual or potential adverse event has … research has examined the predictive validity of NLP algorithms for detection of safety incidents and adverse

224. Final Progress Report: Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/umoren-report.pdf
     January 01, 2025 - Significance This contribution is significant because adverse events occur in up to 70% of pediatric … Human factors are the root cause of 67% of avoidable adverse events on transport, with most adverse … Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants. … Factors Associated with Adverse Events during Tracheal Intubation in the NICU. … Epidemiology of adverse events in air medical transport.

225. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
     January 01, 2002 - Adverse events including device- related deaths and serious injuries must be reported to the FDA and … How do existing incident reports help to describe adverse events in terms of infusion device programming … Our study’s initial findings give us the opportunity to better understand actual adverse events that … It is possible that practitioners who are involved in adverse events that are reported in the MAUDE … The methods described provide a useful basis for study the evolution of adverse events.

226. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - events. … What are safety events in the clinical area? What systems may have led to the events? … events resulting in harm. … Adverse event reporting systems are common in hospitals. … Slide 17: Staff Safety Assessment Say: Adverse reporting systems, sentinel events, and claims data

227. Table 7B.1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
     June 02, 2025 - Table VII.B.1 – Distribution of numbers of Chronic Condition Indicators per patient and adverse … events across sites based on GAPPS study analytic sample (n= 3,442) Chronic Condition Indicators … <0.001 3 or more body systems 125 (3.6%) 0.27 <0.001 Table VII.B.2 – Analysis of differences in adverse

228. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … events. … events and other defects. … events.

229. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
     January 01, 2025 - Our preliminary single-PICU data documented adverse TI-associated events (TIAEs) occur among >20%. … Discussion: Adverse TI events were common across diverse pediatric ICUs. … Impact of trainee level & provider type on tracheal intubate success & associated adverse events. … Association of vagolytic and ketamine use with tracheal associated adverse events. … Substantial site-level variance exists in adverse tracheal intubation associated events: NEAR4KIDS.

230. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
     January 01, 2003 - Relationship between medication errors and adverse drug events. … Incidence of adverse events and negligence in hospitalized patients. … drug events, and adverse drug reactions. … Adverse Drug Prevention Study Group. The costs of adverse drug events in hospitalized patients. … Adverse drug events in hospitalized patients.

231. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_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.

232. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (   PDF , 109 KB ) … Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance   … News Media and Health Care Providers at the Crossroads of Medical Adverse Events (   PDF , 129 KB ) … Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency … Drug Events: Study Methods (   PDF , 646 KB ) Andrew L.

233. Presentation: Science of Improving Patient Safety and Identifying Defects
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
     December 01, 2017 - events Most hospital adverse events are AVOIDABLE Science of Improving Patient Safety … In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … events resulting in harm. … events and other defects.

234. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
     February 21, 2008 - Medical Errors and Adverse Events at Hospital Discharge Errors and Adverse Events Are Common on Both … 49, 50 3 Adverse Drug Events: Common, Serious, and Costly Adverse drug events (ADEs) are the … Adverse events among medical patients after discharge from hospital. … The costs of adverse drug events in hospitalized patients. … Events at Hospital Discharge Errors and Adverse Events Are Common on Both Sides of the Transition

235. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - 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 potentially lead to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … Slide 16 Say: A good response to adverse events really hinges on knowing about them immediately … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events

236. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - their expectations. 11 Therefore, systematic elicitation of patients’ experiences related to safety events … diagnostic breakdowns during transitions among clinical settings. 19 , 25 Assessing the impact of adverse … events on the health and well-being of patients. 26 Understanding the impact of diagnostic problems … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors … But patients and families do not describe adverse diagnostic events with such uniformity.

237. AHRQ-Funded Patient Safety Research Featured in Health Affairs | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/healthaffairs.html
     March 01, 2019 - patient-safety efforts nationwide, AHRQ has funded studies that aim to reduce medication errors and adverse … events, improve communication strategies that support better care coordination, and lower the rate of

238. Prologue: Technology and Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
     June 02, 2025 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … drug events; reduce costs through streamlining processes and providing more targeted, efficient care … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … drug events.

239. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of

240. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - We have since come to realize that preventable medical deaths and adverse events happen in Wisconsin … events? … The IOM estimates that preventable adverse drug events resulted in approximately $2 billion in increased … events. … Systems analysis of adverse drug events. JAMA 1995;288:501–13. 3. Borden S. U.S.