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Showing results for "adverse events".
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261. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Further, 13.6 percent of the adverse events led to the death of the patient. … Death occurred in 6.6 percent (SD of 1.2 percent) of the adverse events. … Incidence of adverse events and negligence in hospitalized patients. … Incidence and types of adverse events and negligent care in Utah and Colorado. … The nature of adverse events in hospitalized patients.

262. Universal ICU Decolonization: An Enhanced Protocol | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/universal-icu-decolonization/index.html
     September 01, 2013 - Safety and Adverse Events The REDUCE MRSA Trial (Randomized Evaluation of Decolonization … Safety and Adverse Events Authors University of California Irvine Susan Huang, MD, MPH Adrijana

263. Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
     January 01, 2024 - Scope Adverse events (AEs) following spine surgery negatively impact patients, surgeons, and the healthcare … Definition of the outcome variables: adverse events We defined an AE as the occurrence of new ICD- … Improved capture of adverse events after spinal surgery procedures with a longitudinal administrative … A machine learning approach for predictive models of adverse events following spine surgery. … Accuracy of a machine learning approach for predicting adverse events after spine surgery.

264. Final Progress Report: Automated Lab Test Followup To Reduce Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/greenes-report.pdf
     January 01, 2025 - As a secondary measure, rates of adverse events were calculated. … As secondary analysis, we will compare the rates of adverse events in Phases 2 and 3. … Although we attempt to detect adverse events attributable to these errors, we expect these adverse … Our study may not have adequate power to detect a difference in rates of adverse events. … Thus, our study may lead to a decrease in the rate of resulting adverse events.

265. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … For example, Medication or Other Substance events that were reported as Adverse reaction in patient

266. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
     August 21, 2015 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of

267. Final Progress Report: Application of Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/singh-report.pdf
     January 01, 2025 - events. … Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational … Performance of a trigger tool for identifying adverse events in oncology. … The ability of triggers to retrospectively predict potentially preventable adverse events in a sample … The accuracy of trigger tools to detect preventable adverse events in primary care: a systematic review

268. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
     April 01, 2025 - Incidence of adverse events and negligence in hospitalized patients. … The nature of adverse events in hospitalized patients. … Patient record review of the incidence, consequences, and causes of diagnostic adverse events. … “Never events” and the quest to reduce preventable harm. … Serious Reportable Events in Healthcare 2011.  

269. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
     January 01, 2004 - The cost of adverse drug events in hospitalized patients. JAMA 1997;227(4):307–12. 7. … Detecting adverse events using information technology. JAMIA 2003c;10(2):115–28. 9. … Using information technology to screen for adverse drug events. … Identifying hospital admissions due to adverse drug events using a computer-based monitor. … Comparison of medication errors, adverse drug events, and intercepted errors Table 2.

270. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
     January 01, 2017 - events Events causing mobilization episode to stop Intervention Agitation (1) Control Agitation (2) … 9 patients had 14 adverse events (<1% of activities) Falls to knees without injury (5) Systolic blood … events 6. … events ranged from agitation to transient physiological events to dislodgements and to falls (none of … the falls were considered serious) Adverse events ranged from 2.3 to 8.7 per 100 patients3-5 3.

271. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap2.html
     December 01, 2014 - vs. 2010, and Baseline Projections Made in 2011 on the Additional Inpatient Mortality per HAC Adverse … Drug Events 1,621,000 1,320,000 301,000 19% $1,505,000,000 6,020 Catheter-Associated … $149,600,000 1,628 Falls 260,000 240,000 20,000 8% $144,680,000 1,100 Obstetric Adverse … Events (2012 data used in lieu of 2013) 82,000 77,000 5,000 6% $15,000,000 7 Pressure

272. The Five Principles of Effective Primary Care-Based Care Coordination for Reducing Potentially Preventable Readmissions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
     March 01, 2021 - events. … If left unaddressed, behavioral health and social needs are key risk factors for postdischarge adverse … events. … events increases after hospitalization. … events.

273. Acknowledgments | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/acknowledgements.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Events in Labor and Delivery Patient Safety Culture and Medical Liability—Recommendations for Measurement … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home Advances in Patient Safety

274. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - The nature of adverse events in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. 16. … Medication errors and adverse drug events in pediatric inpatients. … The costs of adverse drug events in hospitalized patients.

275. Final Progress Report: Prescription Opioid Use Trajectories and Risk Factors Associated with Opioid-Related Hospitalizations in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/wei-report.pdf
     January 01, 2024 - Trajectories of Prescription Opioid Dose and Risk of Opioid-Related Adverse Events Among Older Adults—A … Association of Injury After Prescription Opioid Initiation with Risk of Opioid-Related Adverse Events … Prescription opioid exposures and adverse outcomes among older adults. … Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare … Association of Injury After Prescription Opioid Initiation with Risk of Opioid-Related Adverse Events

276. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
     June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form Changing the System 12 What Happened? … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.   … Completion Guide for the Four Moments of Antibiotic Decision Making Form Learning From Antibiotic-Associated Adverse … Events Changing the System 19 Disclaimer The findings and recommendations in this presentation

277. Detailed Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
     August 01, 2022 - The grantee reported the following findings about the first 125 adverse events resolved through the communication … events). … Communication-sensitive adverse events (CSAEs). 9 the term “CSAE” was coined by the UW project and defined … The grantee reported findings on four composite scores that measure perinatal adverse events: the Adverse … The thinking was that the DRPs would be utilized by the hospitals to disclose adverse events, and the

278. USER GUIDE: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/user-guide-covid-19-vaccination-tracking-tool-nursing-facilities.pdf
     July 01, 2022 - o How many and what type of adverse events occurred by specific vaccine brand. … This is important because if you are seeing increased adverse events related to a specific vaccine … This is important because if you are seeing increased adverse events related to a specific vaccine administrator … An additional pie chart (Figure 18) illustrates Resident or Staff Adverse Events by Manufacturer. … Figure 18 – Example Adverse Events pie chart Figure 17 - Example Vaccination Status To-Date pie chart

279. Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
     March 10, 2008 - These tools can be used to help hospitals identify potential adverse events that might need further … study and also to enable users to assess the occurrence of in-hospital adverse events using routinely … Adverse events among medical patients after discharge from hospital. … The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Knowledge translation and patient safety: The Canadian adverse events study.

280. Transforming Care for People Living with Multiple Chronic Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
     November 17, 2020 - risk” will go on to develop MCC • Targeted interventions to improve health and reduce the risk of adverse … events and complications among those with multiple chronic conditions (e.g., diabetes, depression, … interventions for those who have complex management issues and who are at “high risk” for avoidable adverse … events, and require a focus on preventing decline, maximizing functioning, and improving quality of