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Showing results for "adverse events".
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2641. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
      December 01, 2017 - So one event can lead to multiple other events, and I’m now on the slide – that is slide 6, I think – … Adverse drug events can lead to urinary retention, so the use of the catheter.

2642. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=218
      January 01, 2024 - Keywords: Healthcare Cost and Utilization Project (HCUP), Hospital Readmissions, Surgery, Risk, Adverse … Events, Outcomes Rosenman ED , Vrablik MC , Brolliar SM Targeted simulation-based leadership

2643. Discussion of Findings | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/findings.html
      March 01, 2017 - to improve medication safety in primary care should improve not only safety, including reductions in adverse … drug events, but also quality of care.

2644. Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Sehgal_64.pdf
      April 02, 2008 - Background/Assessment/Recommendation) Nurse staffing ratios “Falls” Medication errors/preventable adverse … drug events “Medication reconciliation” Culture of safety “Communication” Look-alike, sound-alike

2645. Six Building Blocks How-To-Implement Toolkit: Prepare and Launch Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-prepare.pdf
      February 18, 2021 - For instance, the champion could share a story of an adverse outcome—such as overdose, death, or diversion—for

2646. White Paper - Redefining Primary Care for the 21st Century (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/white_paper.pdf
      January 01, 2020 - Forum: Efforts to Measure and Improve Patient-Centered Primary Care http://www.mathematica-mpr.com/events … primarycaremeasures.ahrq.gov/team-based-care/downloads/ccteam/Team-based_Primary_Care_Atlas.pdf http://www.mathematica-mpr.com/events … /chce-forum-measuring-comprehensiveness-of-primary-care http://www.mathematica-mpr.com/events/chce-forum-measuring-comprehensiveness-of-primary-care

2647. Section 4. Identifying Strategies | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptflow/section4.html
      July 01, 2018 - staff-level performance improvement team brainstorming various strategies, testing them (e.g., through kaizen events

2648. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
      January 01, 2024 - from hospital specific analyses because of the difficulty in estimating rates of relatively rare events … study, we feel that all maternal deaths and near misses should be monitored and evaluated as sentinel events … Significant adverse outcomes are rare, prompting the need for Maternal Health Surveillance Indicators … How often are potential patient safety events present on admission?

2649. Final Progress Report: Watchful Waiting as a Strategy for Reducing Low-value Spinal Imaging (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/fenton-report.pdf
      January 01, 2025 - use and efficacy of advising watchful waiting with actual low back pain patients; and d) have no adverse … Is Excessive Resource Utilization an Adverse Event? JAMA. 2017 Feb 28;317(8):849–50. 5.

2650. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
      January 01, 2025 - This data repository also enabled our team to respond rapidly to unanticipated events and to make important … critical decision method interviews, we learned that less than 20% of ED clinicians were aware of adverse … clinical events that occurred after their involvement in the patients’ care ended.

2651. Final Progress Report: Incorporating Temporary Health States into Decision Support (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/col-report.pdf
      January 01, 2024 - therapy is decreasing in popularity due to its known risks of CVD, breast cancer, and venous thrombotic events … Decision aids reduced the use of discretionary surgery without apparent adverse effects on health outcomes … PROTOTYPE Appendix C: SELECTED ABSTRACTS FROM DIRECTLY RELATED PUBLICATIONS Appendix D: TIMELINE OF MAJOR EVENTS

2652. Defining-Critically-Ill-Icu-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/defining-critically-ill-icu-transcript.docx
      September 24, 2015 - Specifically, the events listed here on the slide are things that can be considered defects, or they … For events like CLABSI, CAUTI, or VAE, each month we review charts of these patients to try to find themes … also have an anonymous, electronic reporting system that allows our staff to enter information about events … Not for any adverse reason.

2653. Defining Critically Ill in the ICU; Alternatives to Catheters; Using CUSP Staff Safety Assessment and the Learning From Defects Tool to Improve Safety Culture | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/defining-critically-ill-icu-transcript.html
      December 01, 2017 - Specifically, the events listed here on the slide are things that can be considered defects, or they … For events like CLABSI, CAUTI, or VAE, each month we review charts of these patients to try to find themes … also have an anonymous, electronic reporting system that allows our staff to enter information about events … Not for any adverse reason.

2654. Final Progress Report: National Claims-Based Quality Measures for Surgical Site Infections (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/platt-report.pdf
      January 01, 2025 - Second, adverse events may be higher in hospitals performing fewer procedures (described below). … national (CMS value-based purchasing) and state level for targeting these high cost and high morbidity events … ICD-9) codes suggestive of an SSI within 90 days of the surgical procedure were used to identify SSI events … Evaluation of Diagnosis Codes Used to Identify Candidate SSI Events during CMS Validation.

2655. TeamSTEPPS Fundamentals Course: Module 1. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
      June 01, 2019 - Prevent adverse drug events. Prevent central line infections.

2656. Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
      January 01, 2004 - and health, e.g., reductions in mortality, lessened disability, improved functioning, and decreased adverse … events?

2657. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
      January 01, 2003 - availability of resources (e.g., financial, skilled care providers), and history (e.g., experience with adverse … only those errors that cause serious harm as a significant threat to patient safety; and since such events

2658. Best Practices in the Diagnosis and Treatment of Sepsis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/sepsis-facilitator-guide.pdf
      November 01, 2019 - worse outcomes after the decision was made to de-escalate therapy, and were spared from potential adverse … events associated with broad-spectrum antibiotic use.

2659. Best Practices in the Diagnosis and Treatment of Clostridioides difficile Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/CDI-facilitator-guide.pdf
      November 01, 2019 - Although all antipseudomonal beta-lactam antibiotics have the potential for adverse events, if you are

2660. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults-references.html
      September 01, 2024 - Association of a calcium channel blocker and diuretic prescribing cascade with adverse events: a population-based