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Showing results for "adverse events".
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281. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - events focus on re-education, re-training, disciplinary actions, or the creation of new policies. … A pre-scripted immediate response to events, along with a tightened timeline for event reviews. … event or near miss is the prevention of future adverse events. … If these factors can be identified and modified, the chance of similar events can be reduced. … The systems approach recognizes that all adverse events have multiple contributing factors, many of which

282. Table 7.B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-6b-table-b1.pdf
     June 02, 2025 - Table 7.B Table VI.B.1 Identifying a record with one or more adverse … events Specificity Sensitivity Internal primary reviewers vs External expert primary reviewers 0.91

283. 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.

284. Highlights From AHRQ's Patient Safety Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/psnet.html
     March 01, 2025 - related to patient safety, features a new set of articles including: Ambulatory medication errors and adverse … events involved in medicine-related malpractice cases from 2011 to 2021 .

285. Understanding SOPS Surveys: A Primer for New Users (Webcast) - Famolaro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-SOPS_101_Webcast-FAMOLARO.pdf
     January 01, 2020 - 2.0 Webcast Replay, PowerPoint slides, and Transcript are available on the AHRQ SOPS website under Events … Hospital SOPS to AHRQ Patient Safety Indicator (PSI) adverse event rates 3. … Journal of Patient Safety. 8(3), 131-139. 38 HSOPS 1.0 & Patient Safety Indicator (PSI) Adverse Event … en t R at e— PS I C om po si te Higher patient safety culture scores associated with lower adverse … Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events.

286. Information to Help Hospitals Get Started
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pptx
     July 23, 2010 - For example, one study found that more than 70% of adverse events are caused by breakdowns in communication … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … Common complications post-discharge are adverse drug events, healthcare-associated infections, and procedural … complications include adverse drug events, healthcare-associated infections, and procedural complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.

287. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.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 … Drug Events During Transfer of Care from Hospital to Home Carole Hemmelgarn Three … Some of the key elements of CRPs are reporting and responding to adverse events, continuous communication … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals.

288. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
     January 01, 2024 - drug events or potential adverse drug events by the physician reviewers. … The combined incidence rate of adverse drug events and potential adverse drug events in the intervention … Emergency hospitalizations for adverse drug events in older Americans. … Adverse events among medical patients after discharge from hospital. … Adverse drug events resulting from patient errors in older adults.

289. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-appendix.html
     November 01, 2017 - Drug Events (("Drug therapy/adverse effects"[mh] OR "drug interactions"[mh] OR "anaphylaxis"[mh] OR … [tiab] OR "adverse drug events"[tiab] OR "adverse drug reaction"[tiab] OR "adverse drug reactions"[tiab … Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a … Costs associated with anesthesia-related adverse events during labor and delivery in New York state, … Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay.

290. AHRQ Study Highlights Caregiver Needs in Mobile Health App Adoption | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/917.html
     June 01, 2024 - June 18, 2024 AHRQ Stats: Adverse Drug Events Involving Hypoglycemic Agents In 2021, 7.5 percent of … percent of patients with an “other” or unknown race, and 4.0 percent of White patients experienced adverse … inpatient events involving hypoglycemic agents, which are used to control blood sugar levels in diabetic … Interdisciplinary videoconference model for identifying potential adverse transition of care events following

291. Final Progress Report: Quality of bag mask ventilation in critically ill children (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/nishisaki-report.pdf
     January 01, 2024 - tracheal intubation- associated events (TIAEs) and severe oxygen desaturation during tracheal intubation … Desaturation (SpO2<80%) or adverse TIAEs occurred in 5/20 (25%) of children with high-quality breath … Key Words mask ventilation, quality, child, critically ill, adverse events, oxygen desaturation … We identified and reported that 20% of TI are associated with adverse TI-associated events (TIAEs … events during TI procedure are also associated with a longer duration of mechanical ventilation, longer

292. 018-Revision-Summary-Contact-Precautions (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
     October 01, 2024 - events (e.g., falls, pressure injuries), increased symptoms of depression and anxiety, and decreased … patient satisfaction.16 · Adverse outcomes have not been identified in some more recent, higher-quality … events.11 A study that evaluated patients’ mental state upon entering the study found patients no more … Adverse outcomes associated with Contact Precautions: a review of the literature. … The effect of universal glove and gown use on adverse events in intensive care unit patients.

293. The Science of Improving Patient Safety and Identifying Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
     December 01, 2017 - Surgery is linked to 50% of all hospital adverse events. … Most hospital adverse events are AVOIDABLE. Slide 6: How Do These Errors Happen? … Slide 16: Communication Breakdowns 6 Images: Four bar graphs showing root causes of adverse events … including sentinel events, medication errors, delays in treatment, and infection-associated events from … What systems may have led to these events?

294. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - Conference attendees learn how specific MedSun reports have affected FDA’s response to adverse events … events, motivate users to report those events, and train users to write complete and accurate reports … about the events. … Step 5: Improve users’ recognition of medical device adverse events. … Step 6: Motivate users to report device adverse events within their own institutions.

295. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - The purpose of this study was to examine whether adverse events or complications in hospitals occur … Several recent studies, as well as an IOM report, show an increase in mortality and adverse events with … Relation between malpractice claims and adverse events due to negligence. … Incidence of adverse events and negligence in hospitalized patients. … Incidence of and risk factors for adverse events and negligent care in Colorado and Utah in 1992.

296. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - Do they believe the organization is aware of all the patient harm events? … Have they heard of events that should have been reported but were not reported? … Other methods of reporting CANDOR events may include in-person reporting. … The sole objective of the Event Investigation and Analysis of an adverse event or near miss is to prevent … future adverse events.

297. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
     January 01, 2007 - All significant adverse events (e.g., unexpected deaths and hospitalizations) were to be reported for … Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical … Incidence of adverse drug events and potential adverse drug events: Implications for prevention. … Incidence and preventability of adverse drug events in hospitalized patients. … Adverse events in primary care identified from a risk- management database.

298. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
     January 01, 2017 - events. … What are safety events in the clinical area? What systems may have led to the events? … events resulting in harm. … Adverse event reporting systems are common in hospitals. … Slide 16 Staff Safety Assessment SAY: Adverse reporting systems, sentinel events, and claims data

299. National Healthcare Safety Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/national-measures/index.html
     April 01, 2025 - AHRQ Quality and Safety Review System The Quality and Safety Review System (QSRS) measures the rate of adverse … events among hospital patients covered by Medicare and creates a nationally representative baseline … up for the National Action Alliance listserv to receive the monthly newsletter with new resources, events

300. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … understanding and correcting weaknesses in the health care delivery system and to preventing actual adverse … The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident … Does error and adverse event reporting by physicians and nurses differ?