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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/ASB-UTI-slides.pptx
November 01, 2019 - Improving Antibiotic Use – Acute Care
Treatment of ASB May Cause Harm6-9, 14
Treatment is associated with—
Adverse … events and development of resistance
An increased risk of subsequent UTIs
9
ASB and UTI
AHRQ Safety
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lbpinject-topicref.pdf
March 03, 2014 - years of age and remains common in persons 65 years of age and older.3 Low back
pain can have major adverse … health care utilization
• For Key Question 4: Harms, including bleeding, infection, neurological events
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/047-evidence-behind-decolonization-strategies-notes.docx
October 01, 2024 - Slide 6
Decolonization Prevents a Cascade of Unfortunate Events
SAY:
HAIs represent a cascade of unfortunate … events. … Findings consistently identify a sizable reduction in both MDRO carriage and bloodstream infection events … There is evidence to support iodophor as better tolerated than mupirocin, with patients reporting fewer adverse … events and higher levels of satisfaction with the decolonization experience compared with mupirocin.
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www.ahrq.gov/sites/default/files/2024-09/temte-report.pdf
January 01, 2024 - Outlying events were identified as those with an
absolute standardized residual of 2.0 or greater, thus … In addition, occasional “interesting” events that were
significantly displaced from the regression line … Error in medicine: adverse events in intensive care.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
January 01, 2004 - drug interactions, the outcome measure is the number of the targeted
contraindicated coprescribing events … , divided by the sum of the number of the
contraindicated coprescribing events plus the desired coprescribing … Impact of
basic computerized prescribing on outpatient
medication errors and adverse drug events.
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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/2024-09/ratwani-report.pdf
January 01, 2024 - In addition, the report suggested that there are serious medical errors and adverse patient
outcomes … Simulation events were retrieved from the Society for Academic Emergency
Medicine (SAEM) simulation
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www.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
July 01, 2004 - collaborative patient-physician relationship (e.g.,
“Make sure your doctor knows about any allergies and adverse … Medications and adverse drug events are a key and often-cited patient safety
topic that patient behavior
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
July 01, 2004 - collaborative patient-physician relationship (e.g.,
“Make sure your doctor knows about any allergies and adverse … Medications and adverse drug events are a key and often-cited patient safety
topic that patient behavior
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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/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/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/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/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/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/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/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/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/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/2024-01/chetty-report.pdf
January 01, 2024 - As one may suspect, various factors contribute to
a rehospitalization or an adverse event.