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2501. Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/urine-culture-practices-icu-slides.html
      December 01, 2017 - Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys Slide 1 Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys Mohamad Fakih, MD, MPH Medical Director, Infect…

2502. Hybrid Cardiac Rehabilitationi (HYCR) Tools and Resources Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/hycr-tools-resources-guide.pdf
      April 28, 2023 - ......................................................................................... 84 4a: Adverse … Events and Emergency Protocol ...................................................................... … The contributor for each resource is included. 4a: Adverse Events and Emergency Protocol Contributor … • Implement record of critical and non-critical events and complications on site vs HYCR • Although

2503. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
      April 01, 2018 - Model Probability Estimates References Cut Set Contributed Probability Events

2504. Diagnostic Safety Issue Brief 21 Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
      August 01, 2024 - However, it is difficult to infer changes in safety or adverse outcomes based on test use or even inappropriate … consider the total value of diagnostic stewardship, including downstream effects on length of stay, adverse … events, clinician satisfaction, and patient experience. … Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events.

2505. Making Healthcare Safer Practices: 10. Harms Due to Opioids (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/opioids-1.pdf
      March 01, 2020 - National Action Plan for Adverse Drug Event Prevention.Washington, DC: U.S. … events, and patient-reported outcomes. … Of 103 patients in this observational study, no cases of severe precipitated withdrawal or adverse events … No serious adverse events related to treatment occurred. … No cases of severe precipitated withdrawal and no serious adverse events were observed.

2506. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
      January 01, 2006 - Six Sigma initiatives in these areas have resulted in a 44 percent reduction in adverse drug events,

2507. Nutritional Research Series: Volume 5: Comparison of Translational Patterns in Two Nutrient–Disease Associations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp5.pdf
      October 01, 2011 - The trials were expensive to conduct, and in some cases, they identified adverse effects of nutrient … Figure 1 describes alternative scenarios for the possible cascade of translational events. … Vitamin E supplementation and cardiovascular events in high-risk patients. … Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS) … For randomized trials, we extracted number of events in the intervention and control groups.

2508. Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/final-rapid-cycle-research-guidance.pdf
      June 01, 2015 - http://pbrn.ahrq.gov/events/advanced-methods-primary-care-research-stepped-wedge-design AHRQ PBRN … View the Webinar recording on AHRQ’s PBRN Events page here: https://pbrn.ahrq.gov/events/dissemination … http://pbrn.ahrq.gov/events/advanced-methods- primary-care-research-stepped-wedge-design. … information systems can reduce medical errors and might pose a viable option for the prevention of adverse … drug events.

2509. State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
      January 17, 2024 - can lead to inappropriate treatments, disease progression, preventable hospitalizations, and other adverse … Adverse drug events from medication can often mimic acute medical conditions in older adults, thus contributing … and a “prescribing cascade,” where a second, potentially unnecessary drug is prescribed to treat the adverse … Medications (i.e., polypharmacy and deprescribing, medication reconciliation, and adverse medication … Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: a population-based

2510. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/19604-Coburn-report.pdf
      January 01, 2013 - care facilities during transfers of care may adversely affect the patient’s quality of care, lead to adverse … events, and contribute to the overall cost of the services provided. … and then to the hospital emergency department (ED) can lead to delays in diagnosis and treatment, adverse … events, patient complaints, and increased costs and length of stay.(8-12) The literature suggests that

2511. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
      January 01, 2024 - care facilities during transfers of care may adversely affect the patient’s quality of care, lead to adverse … events, and contribute to the overall cost of the services provided. … and then to the hospital emergency department (ED) can lead to delays in diagnosis and treatment, adverse … events, patient complaints, and increased costs and length of stay.(8-12) The literature suggests that

2512. SOPS Frequently Asked Questions | Agency for Healthcare Research and Quality
      www.ahrq.gov/sops/about/faq/index.html
      June 01, 2022 - Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events … Safety (3 items) Organizational Learning—Continuous Improvement (3 items) Reporting Patient Safety Events … (3 items) HSOPS 2.0 also includes several single item measures that assess: How many patient safety events … Frequency of Events Reported. Hospital Handoffs & Transitions. … One item measuring the number of events the respondent has reported over the past 12 months.

2513. Final Progress Report: Risk Assessment of Pediatric Emergency Transfers (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
      January 01, 2025 - Serious adverse outcomes occurred in 55 reports (31%), including major physiological derangement (15% … subsequent audit of 100 adult inter-hospital transfers over 14 months, Ligtenberg et al. found that adverse … effects occurred in 34% of transports. 2 The study suggests that “70% of these events could have been … issues…”15 In addition, communication was identified as a contributing factor in nearly 70% of sentinel events … In situations when failure events are likely to occur, hazard evaluation techniques can be effectively

2514. Module 3. Falls Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
      October 01, 2014 - Return to Contents   Workbook Content Overview Clinical Content Falls are serious, unwanted events … first session starts by describing what it takes to make a safe work environment in which sharing of events … to define and explain what a fall is, noting that falls should be distinguished from sudden medical events … objectives, which are to: Gain knowledge and skills to understand systems of care and minimize adverse

2515. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
      January 01, 2024 - Scope and Methods: One out of every three adverse drugs events precipitated by a medication error occurs

2516. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=167
      January 01, 2024 - Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events

2517. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=162
      January 01, 2024 - Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse … Events, Patient Safety Jones KM , Mantey J , Mills JP COVID-19 preparedness in Michigan

2518. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=225
      January 01, 2024 - Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention

2519. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
      March 31, 2008 - vulnerable group of patients who are often unable to advocate for themselves and who are at high risk for adverse … admission/discharge diagnoses noted in the discharge summary) Hospital course (a description of the events

2520. “Safeware”: Safety-Critical Computing and Health Care Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Wears_75.pdf
      May 27, 2008 - practices.21 The problem that the technology itself might be inherently unsafe— that it might lead to adverse