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Showing results for "adverse events".
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261. Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/23291-Landrigan-report.pdf
     September 29, 2018 - Handoff-related adverse events decreased by 42%. All changes were p < 0.05. … Handoff-related Adverse Events In total, 1698 reports of handoff-related adverse events were collected … Rate of handoff-related adverse events. … Reported as the number of events per person-year for both major and minor handoff-related adverse events … Does housestaff discontinuity of care increase the risk for preventable adverse events?

262. 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/hacrate2013.html
     January 01, 2018 - Half of these inpatients experienced one or more adverse events that resulted in a prolonged hospital … events—such as adverse drug events, falls, and pressure ulcers—occurred. … Data for obstetric adverse events come from AHRQ Patient Safety Indicators (PSIs) 18 and 19. … events. … events.

263. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/improve-discharge/index.html
     August 01, 2024 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … Events After Discharge Transitions of Care Project BOOST (Better Outcomes for Older Adults through Safer … Events With AHRQ Medication Reconciliation Toolkit (KT-CQUIPS-85) Four New York Providers Use AHRQ … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety in the

264. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/about/areas/improve-discharge.html
     August 01, 2024 - PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse … Readmission Rates With Mortality Rates After Hospital Discharge AHRQ PS Net Primer: Readmissions and Adverse … Events After Discharge Transitions of Care Project BOOST (Better Outcomes for Older Adults through Safer … Events With AHRQ Medication Reconciliation Toolkit (KT-CQUIPS-85) Four New York Providers Use AHRQ … Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective: Patient Safety in the

265. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-facguide.docx
     January 01, 2017 - Slide 10 Safety SAY: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 13 Adverse Effects SAY: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

266. Final Progress Report: Transitional Care Medication Safety and Reducing Medical Liability: Closing the Chasm (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/corbett-report.pdf
     January 01, 2024 - events, and medical liability during hospital-to-community transitions within a complex healthcare … events while minimizing medical liability. … Research indicates that rates of adverse drug events (ADEs) in ambulatory care may be up to four times … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Adverse drug events in ambulatory care. New England Journal of Medicine, 348, 1556–1564.

267. Module 4: Teamwork and Communication | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
     March 01, 2017 - Events Adverse event: An injury to a resident caused by medical intervention rather than by the … events happen. … Slide 29: Disclosure and Apology for Unexpected Adverse Outcomes Immediate Response to an Adverse … Event Next Steps in Responding to an Adverse Event Care for the resident. … Slide 30: How To Communicate About An Adverse Event Speak slowly and use clear language.

268. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - Key Words: patient safety, emergency medicine, errors, adverse events, harm Principal Investigator … Aim 2 – Compare errors and adverse events through active surveillance with those identified through … SCOPE In order to improve a system in any industry, the adverse events that take place within the system … Current knowledge about the number and types of errors and adverse events occurring within emergency … Only a small number of studies have evaluated the epidemiology of errors and adverse events within the

269. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - Hilborne Abstract Physician reporting of adverse events and unsafe situations remains extremely … Because adverse events usually occur as a result of multiple failures, it is imperative that medical … events occur. … events. … events are not the result of one mistake.

270. 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.

271. Develop a Culture of Safety Around Antibiotic Prescribing | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/safety/index.html
     June 01, 2021 - Use Commitment Poster (DOCX) Antibiotic Time Out Tool (DOCX) Identifying Antibiotic–Associated Adverse … Events Form (DOCX) Learning From Antibiotic–Associated Adverse Events Form (DOCX)

272. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Illinois, New York, and Pennsylvania require that adverse events be disclosed to patients. … errors and preventable adverse events, and 3 years of adverse event reports to the New York Patient … JCAHO and New York are the only agencies that address the full range of adverse events, and JCAHO’s … Defining reportable adverse events: a guide for States tracking medical errors. … Patient safety: reporting of adverse events, NEJM 2002; 347(20):1,633–9. 39.

273. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
     April 01, 2025 - Unlike safety “events,” diagnostic errors tend to become evident over time and across different sites … Adverse Events, Diagnostic Adverse Events Defined under the Safety Paradigm section above, adverse event … to an event that results in unintended harm encountered during medical care. 3 In general, medical adverse … events tend to be (but are not always) errors of commission (e.g., wrong site surgery). … Diagnostic adverse events commonly include errors of omission (e.g., failure to order or properly interpret

274. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/about/patient-safety-culture.html
     June 01, 2024 - rates. 2 Hospitals with more positive SOPS scores had: Lower rates of in-hospital complications or adverse … events as measured by AHRQ’s patient safety indicators (PSIs). 3 Patients who reported more positive … Exploring relationships between hospital patient safety culture and adverse events. … The relationship between culture of safety and rate of adverse events in long-term care facilities.

275. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
     August 01, 2022 - Assessment of rates of communication-sensitive adverse events. … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events. … events and maternal adverse events. … Incidence of adverse events and negligence in hospitalized patients.

276. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=66
     January 01, 2024 - pain, and nausea/ vomiting, but a similar risk of adverse possible microbiome-related events. … drug events and possible microbiome-related adverse events including non-Clostridium difficile diarrhea … The duration of the treatment influenced the risk of possible microbiome-related adverse events. … Association of adverse events with antibiotic treatment for urinary tract infection. … Keywords: Antibiotics, Medication, Urinary Tract Infection (UTI), Adverse Drug Events (ADE), Adverse

277. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/15818-Fairbanks-draft-1.pdf
     September 08, 2008 - year in the US7; 5% experience potential adverse drug events,8 and 70% of these, or 3.8 million events … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review. … The nature of adverse events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients. … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review.

278. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. 8 Develop a Measurement Strategy5 WHAT to measure Process … events.”

279. Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/summary.html
     May 01, 2016 - out by the Institute of Medicine, 2   and the AHRQ Common Formats, a which includes definitions of adverse … events and forms for adverse event reporting. … any relevant information collected from other sources within their organizations (such as an existing adverse … the identified goals (patient safety improvement, public monitoring and accountability, research on adverse … Overall, the number of consumer reports was disappointing, given the potential reservoir of adverse events

280. AHRQ Views Blog: We Must Not Underestimate the Impacts of Gun Violence on Healthcare Workers | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/842.html
     December 01, 2022 - Older Opioid Patients Experience More Adverse Events After Injury . … recognized following these tragedies; too often we may assume healthcare workers are hardened to such events … Older Opioid Patients Experience More Adverse Events After Injury Chronic non-cancer pain Medicare … events than those patients who did not experience an injury. … events such as overdoses.