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Showing results for "adverse events".
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2301. Advancing the Science of Patient Safety and Quality Improvement to the Next Level | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/patient-safety-resources/advances-in-hai/hai-article1.html
      June 01, 2014 - We learned that the aviation safety reporting system (ASRS) 8 was successful because it collected adverse … Commission repeatedly noted poor communication and teamwork as major contributing factors to all types of adverse … events. … A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS … Cardiopulmonary monitors and clinically significant events in critically ill children.

2302. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=67
      January 01, 2024 - Keywords: Cardiovascular Conditions, Medication, Stroke, Adverse Drug Events (ADE), Adverse Events,

2303. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=47
      January 01, 2024 - Keywords: Emergency Department, Medical Errors, Adverse Events, Patient Safety Sneed NM , Azuero … They also recorded 30-day major adverse limb events (MALE) defined as major amputation or reintervention

2304. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=6
      January 01, 2024 - Keywords: Kidney Disease and Health, Adverse Events, Risk Powell-Wiley TM , Martinez MF , … Key categories of adverse impacts that emerged included: emergency medical service transport; availability … intensive care units (PICUs) to promote shared situation awareness among medical teams to prevent safety events

2305. Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/unruh-report.pdf
      January 01, 2025 - Composite PSI composite of complications Weighted average of reliability and risk-adjusted rates of adverse … events, such as pressure ulcers, postoperative respiratory failure and postoperative sepsis. … IQIs and PSIs are risk-adjusted hospital rates of mortality and patient safety events obtained from … PSI indicators were rates of adverse events, such as pressure ulcers, postoperative respiratory failure … Licensed nurse staffing and adverse events in hospitals. Med Care 2003 41(1): 142-152.

2306. Final Progress Report: Targeted Delivery of Multiparametric Telemetry Clinical Messages to Mitigate Alarm Fatigue - PERSEUS (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/kobayashi-report.pdf
      January 01, 2024 - 536 warnings per day after an alarm fatigue-mitigating intervention (i.e., a 43% reduction) without adverse … events. … , such as malignant arrhythmias, and false events (e.g., patient movement and lead disconnections). … Adjudicated/Annotated Telemetry signals for Medically Important and Clinically Significant events-0 ( … Adjudicated/Annotated Telemetry signals for Medically Important and Clinically Significant events-1 (

2307. CHIPRA Pediatric Quality Measures Program (PQMP) Candidate Measure Submission Form (CPCF) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-5.8.pdf
      January 01, 2014 - survey evaluating instances of communication with the pediatrician, referred to as communication “events … Independent raters also coded the communication events from videotapes. … outcomes, self-reported health, adherence to treatment, preventive care, health care resource use, adverse … events, and technical quality of care. … information were obtained from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse

2308. AHRQ Patient Safety Tools and Resources (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/pstools/patient-safety-tools-flyer-2021update.pdf
      April 01, 2021 - PSOs can help providers develop successful approaches to improving quality and reducing adverse outcomes … The Common Formats can be used to collect data on all types of adverse events, near misses, and unsafe … of care inside hospitals to focus on potentially avoidable complications and healthcare-associated events

2309. Chapter 2. Building the Project Foundation: Project Teams and Scope | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-2.html
      July 01, 2022 - point could be the facility's readmission rates (the Finance department usually creates these data), adverse … drug events (ADEs) for the facility (the Pharmacy department usually collects these data), or data specific

2310. Chapter 2. Building the Project Foundation: Project Teams and Scope | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/match/chapter-2.html
      July 01, 2022 - point could be the facility's readmission rates (the Finance department usually creates these data), adverse … drug events (ADEs) for the facility (the Pharmacy department usually collects these data), or data specific

2311. Nurse-Driven Early Mobility Protocols: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
      January 01, 2017 - ventilator length of stay, ICU and hospital length of stay, incidents and duration of delirium, and adverse … events.

2312. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/nursedr-early-mobility-protocols-facguide.docx
      January 01, 2017 - ventilator length of stay, ICU and hospital length of stay, incidents and duration of delirium, and adverse … events.

2313. Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
      January 01, 2024 - case to hospital leadership of the return on investment of hiring these personnel (i.e., in reducing adverse … drug events and inpatient length of stay). … Medication Reconciliation to Prevent Adverse Drug Events. … Secondary Medication Reconciliation to Prevent Adverse Drug Events 2018. http://www.ihi.org/Topics/ADEsMedicationReconciliation

2314. Final Progress Report: Developing and Disseminating a Patient Safety Risk Assessment (PSRA) Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/joseph2-report.pdf
      September 29, 2015 - with other factors (e.g., organizational culture, operation) in complex ways, impacting the risk of adverse … events. … It will be a significant step forward in enhancing patient and staff safety through reducing adverse … Safety First: Designing Healthcare Spaces To Avoid Adverse Events. Healthcare Design Magazine. … Safety by Design: How Teams Can Proactively Use Facility Design to Reduce Adverse Events.

2315. Final Progress Report: Developing and Disseminating a Patient Safety Risk Assessment (PSRA) Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/joseph2-report.pdf
      January 01, 2024 - with other factors (e.g., organizational culture, operation) in complex ways, impacting the risk of adverse … events. … It will be a significant step forward in enhancing patient and staff safety through reducing adverse … Safety First: Designing Healthcare Spaces To Avoid Adverse Events. Healthcare Design Magazine. … Safety by Design: How Teams Can Proactively Use Facility Design to Reduce Adverse Events.

2316. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
      April 14, 2004 - approve consent forms (where applicable), monitor ongoing studies, and investigate reports of alleged adverse … events in approved studies. … Instruments The AAFP PSRS accepted anonymous reports from clinicians, staff, and patients concerning events … For the General Errors study, these could be any type of events, including office process or knowledge … For the Testing Process Errors study, reported events were related only to laboratory tests, diagnostic

2317. Final Progress Report: Valuation of a Simple Tool for Chest Pain Patient Risk-Stratification in North America (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/mader-poronsky-report.pdf
      January 01, 2024 - cohort, this simple outcome predictor has been shown to accurately quantify the likelihood of a major adverse

2318. A Clinical Assessment Program to Evaluate the Safety of Patient Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Snow.pdf
      January 01, 2010 - errors of omission, such as not providing perioperative beta-blockade to patients at risk for cardiac events … , thus increasing the patient’s risk of an adverse event and reducing the safety of their care. … Adverse events and their association with treatment regimens in the Diabetes Control and Complications

2319. Creating a Curriculum for Training Health Profession Faculty Leaders (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
      March 31, 2004 - This represents a significant culture shift, which can be prompted by tragic events (as in the case … from multiple professions together to search for the multiple contributory factors at the root of an adverse … in patient safety concepts as well as in fostering cultural changes leading to open discussion of adverse … events and an improved rate of safety-based changes.26 Lack of interprofessional education related

2320. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pdf
      July 01, 2012 - LEP The Story of Willie Ramirez SAY: To illustrate why LEP patients are at risk of patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study. … is inspired by the 2006 book by John Kotter, Our Iceberg Is Melting: Changing and Succeeding Under Adverse … Our iceberg is melting: changing and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events