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www.ahrq.gov/sites/default/files/publications2/files/calibrate-dx-guide.pdf
October 01, 2022 - Abdominal pain, shortness of breath,
abnormal uterine bleeding
Unexpected trajectories Specific events … • A Fishbone diagram (Appendix C), modified for diagnostic safety
events, can be used to break down … Calibration exercises could also identify cases for existing teams that review quality and safety events … Systems thinking is an essential additional lens to analyze diagnostic events. … reasoning evolved rather than
focusing on the ultimate accuracy of the diagnosis or any potential adverse
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtools.docx
January 01, 2013 - this effort is a shift of thinking and culture, from regarding falls as inevitable to seeing them as events … “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events resulting … Hospital management seems interested in patient safety only after an adverse event happens
1
2
3 … Shift changes are problematic for patients in this hospital
1
2
3
4
5
SECTION G: Number of Events … Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls
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www.ahrq.gov/research/findings/studies/index.html?page=19
January 01, 2024 - Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Electronic Health Records ( … Delays in the diagnosis of central nervous system (CNS) tumors in children may lead to adverse outcomes
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod2.html
October 01, 2014 - When procedures for team communication are in place, the number of "adverse events" (negative effects … three main components are to:
Gain knowledge and skills to understand systems of care and minimize adverse
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www.ahrq.gov/policymakers/chipra/overview/background/next-steps2.html
December 01, 2009 - Health care-associated infections are regarded as "never events," that is, adverse events that should
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/17354-Chetty-report.pdf
September 29, 2010 - As one may suspect, various factors contribute to
a rehospitalization or an adverse event.
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www.ahrq.gov/sites/default/files/2024-01/chetty-report.pdf
January 01, 2024 - As one may suspect, various factors contribute to
a rehospitalization or an adverse event.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cpcq-scoring.pdf
May 01, 2017 - Conclusions: Multiple imputation is a clear leader in accuracy for dealing with
missing data, though even in adverse
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-implementation-guide.pdf
March 01, 2023 - Messaging for a Clinical Manager
Clinical Manager
CR Benefits -Improving patient health
-Reducing adverse … events
Evidence of Benefits -CR reduces morbidity and mortality and improves quality of life
-CR … implementation
Ways to Reduce
Barrier/Opposition
Generally, CR improves patient health and reduces adverse … events,
which are metrics tracked, incentivized by some value-based payers
Example: CR reduces the
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www.ahrq.gov/research/findings/studies/index.html?page=27
January 01, 2024 - They concluded that minimum surgical volumes and predicted events criteria are required to make hospital … ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% which would prevent 3,169 ASCVD events … to identify novel patterns of medication clusters (termed 'pharmacophenotypes') correlated with ICU adverse … events (e.g., fluid overload) and patient-centered outcomes (e.g., mortality).
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www.ahrq.gov/sites/default/files/wysiwyg/innovations/will-work/InnovationAdoptionGuide.pdf
September 01, 2008 - The Institute for Healthcare Improvement has developed an Events
Prevented Calculator that computes … the ROI and lives saved by quality
improvement efforts focused on reducing adverse events:
http://www.ihi.org … innovation without a positive ROI include:
• Addressing major defects, such as intolerably high rates of adverse … of our
measures of efficiency, initially, we wanted not to see
indicators that we were having an adverse … ROI and lives saved by quality improvement efforts focused on reducing adverse events: http://www.ihi.org
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www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-c.html
July 01, 2021 - effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse … drug events, and preventable hospital readmissions ( Agency for Healthcare Research and Quality, 2018 … Safety Organizations program, which enables health care providers to uniformly report patient safety events
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp4.pdf
February 01, 2012 - For RCTs we extracted number of events in the intervention and control groups. … We back-calculated the ―effective counts‖ of events in each category of EPA and DHA intake
based on … different considerations compared with other nutrients whose
reference intakes are set to prevent adverse … Effects of eicosapentaenoic acid on major
coronary events in hypercholesterolaemic
patients (JELIS) … Omega-3 dietary
supplements and the risk of cardiovascular
events: a systematic review.
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www.ahrq.gov/research/findings/studies/index.html?page=121
January 01, 2024 - professional societies, recommend “routine screening for all older adult patients at higher risk for adverse … transparency in reporting processes, greater opportunity to address complaints, explicit policies for events
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www.ahrq.gov/sites/default/files/2024-07/kukafka-report.pdf
January 01, 2024 - For example, as described in prospect theory 29, people usually overweight
the probability of rare events … However, they underweight the probability of
rare events when learning from experience 27, 28. … been suggested as a source of
communication barriers between doctors, who may learn about medical events … (such as change of adverse effects from a beneficial vaccine) than in increasing attention to
common … Decisions from experience and the effect of rare events in
risky choice.
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www.ahrq.gov/sops/about/faq.html
February 01, 2023 - Answer: Safety culture surveys are useful for measuring organizational conditions that can lead to adverse … events and patient harm in healthcare organizations. … 3 items)
HSOPS 2.0 also includes:
One survey item that asks respondents 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
March 03, 2008 - Introduction
Patient falls are the most frequently reported adverse event in hospitals and the leading … responsible for closing the gaps in the defensive barriers and reporting
near misses, as well as actual events
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldatasum.html
October 01, 2018 - increased probability of receiving unnecessary diagnostic tests ( Hampers et al., 1999 ), more serious adverse … Language proficiency and adverse events in US hospitals: A pilot study.
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www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
January 01, 2024 - the AHRQ Patient
Safety Indicators, there are significant differences in the risk-adjusted rates of adverse … events depending on whether the POA indicator is used to distinguish between pre-
existing conditions … The use of the POA indicator will increase the
accuracy of the AHRQ PSIs as measures of adverse outcomes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
March 30, 2008 - computerized provider order entry, CPOE) has been touted as a key method to reduce
medication errors and adverse … drug events. … nursing staff not recognizing premedications that were
indicated but not ordered based upon previous adverse