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2641. 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.

2642. 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

2643. 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

2644. 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

2645. 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?

2646. 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.

2647. 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.

2648. 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

2649. 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.

2650. 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.

2651. 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.

2652. 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

2653. 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.

2654. 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?

2655. 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

2656. Attention Deficit Hyperactivity Disorder Performance Measurement Set (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-1.pdf
      February 01, 2012 - organ/limb, already received/performed, other) - contraindicated (patient allergic history, potential adverse … Additional information showed that children often manifest a new more frequent, or severe form of adverse … events described in adults.14 IOM Domains of Health Care Quality Addressed • Effective • Timely

2657. 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

2658. Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/studies/index.html?page=9
      January 01, 2024 - AHRQ Research Studies Sign up: AHRQ Research Studies Email updates Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers. Results 226 to 250 of 12243 Research Studies Displayed Pagination « first « First ‹ previous ‹‹ …

2659. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/029-hand-hygiene-webinar-slides.pptx
      October 01, 2024 - Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs

2660. Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project: toolkit (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/cdifftoolkit.pdf
      September 01, 2012 - Your facility had a notable adverse event that was C. difficile related. … IL, OR, TN, UT) mandate public reporting of facilitywide laboratory-identified (LabID) C. difficile events … rule, starting in 2013, all hospitals will be required to report facilitywide LabID C. difficile events … Excessive use can lead to: o Adverse reactions. o Increased antimicrobial resistance.