Results

Total Results: 2,867 records

Showing results for "adverse events".
Users also searched for: patient safety indicators

2341. 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 (

2342. 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

2343. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=60
      January 01, 2024 - Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Clinical Decision Support (CDS), Health … Vitamins D and E were not significantly associated with all-cause mortality, cardiovascular disease events

2344. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
      January 01, 2024 - ■ Measure Dx: A Resource To Detect, Analyze, and Learn From Diagnostic Safety Events (AHRQ). … Patient record review of the incidence, consequences, and causes of diagnostic adverse events. … Association between cancer-specific adverse event triggers and mortality: a validation study. … An electronic trigger based on care escalation to identify preventable adverse events in hospitalised … Reducing preventable adverse events in obstetrics by improving interprofessional communication skills

2345. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
      August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … on the Centers for Medicare and Medicaid Services’ list of hospital-acquired complications “never events … communication during nurse transitions, for example: • Reduce the incidence of never events by 5 percent

2346. Advancing the Science of Patient Safety and Quality Improvement to the Next Level | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/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.

2347. 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.

2348. 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.

2349. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=358
      January 01, 2024 - Keywords: Newborns/Infants, Children/Adolescents, Medication: Safety, Adverse Drug Events (ADE), Medication … with MI had superior rates of medication adherence but higher rates of postdischarge readmission and adverse

2350. SITUATION MONITORING (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
      January 01, 2008 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverse … events. … Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating data … During a team huddle, response team members could: Discuss critical issues and emerging events. … and prescribe a course of action for future events.

2351. TeamSTEPPS: Rapid Response Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
      January 01, 2008 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverse … events. … •Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating … During a team huddle, response team members could: •Discuss critical issues and emerging events. … and prescribe a course of action for future events.

2352. 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

2353. 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

2354. Improving Patient Safety with the Military Electronic Health Record (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Charles.pdf
      January 24, 2004 - permits physicians to record prescribed medications and view alerts for drug allergies or potential adverse … For more than 10 years, CHCS has issued alerts for potential adverse drug interactions and warnings … patient’s prescription history is viewed in real time and the system alerts providers to any potential adverse … This capability augments patient safety and the quality of medical care by reducing the likelihood of adverse

2355. 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

2356. 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.

2357. 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.

2358. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21114-Lannon-draft-1.pdf
      September 01, 2017 - Solutions for Patient Safety: In 2007, the CERT funded work on identifying Adverse Drug Events using … SPS has reduced falls by 81%, ventilator-associated pneumonias by 47%, adverse drug events by 42%, and … Situation Awareness to Reduce the Rate of UNSAFE Transfers and Serious Safety Events/Evaluating Huddle

2359. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
      January 01, 2024 - Solutions for Patient Safety: In 2007, the CERT funded work on identifying Adverse Drug Events using … SPS has reduced falls by 81%, ventilator-associated pneumonias by 47%, adverse drug events by 42%, and … Situation Awareness to Reduce the Rate of UNSAFE Transfers and Serious Safety Events/Evaluating Huddle

2360. 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