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Showing results for "adverse events".
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321. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
     January 01, 2024 - Systems analysis of adverse drug events. … Adverse drug events in hospitalized patients. … Preventing adverse drug events in hospitalized patients. … The Nature of Adverse Events in Hospitalized Patients. … Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention.

322. Identifying Targets for Improving Antibiotic Use
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-slides.pptx
     November 01, 2019 - Safety Program for Improving Antibiotic Use – Acute Care   6 Identifying Antibiotic-Associated Adverse … Events Multidisciplinary meetings Opportunity to elaborate on issues that have resulted in antibiotic-associated … adverse events or had the potential to cause adverse events that could jeopardize patient safety Decide

323. Board and Senior Leadership PowerPoint Presentations on the AHRQ Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
     October 01, 2015 - • AHRQ QIs are indicators of hospital quality and adverse events that patients may experience as … • Pediatric Quality Indicators (PDIs) reflect quality of care inside hospitals and adverse events … • The PSIs are a set of 18 hospital-level indicators of safety-related adverse events following operations … and Safety • The PDIs are a set of 16 indicators that reflect quality of care inside hospitals and adverse … • PDIs measure events likely preventable through changes at the system or provider level.

324. Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
     January 01, 2024 - events. … events. … Any exacerbation of preoperative hearing changes was reported as an adverse event as well. … In addition, patients were screened for adverse events, including hearing loss and local or systemic … Similar statistical analyses were performed to assess secondary outcomes, safety outcomes, adverse events

325. Changing the System To Improve Antibiotic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/long-term-care/safety/system-change.html
     June 01, 2021 - Improve Antibiotic Safety – Facilitator Guide (DOCX, 2.3 MB) Learning From Antibiotic-Associated Adverse … Events  (DOCX, 226.7 KB)

326. Identifying Targets for Improvement in Antibiotic Decision Making | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/acute-care/safety/improve.html
     November 01, 2019 - Making framework Slides (PPTX) Facilitator Guide (PDF) Identifying Antibiotic–Associated Adverse … Events Form (DOCX)

327. Prologue: Laying the Foundation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
     June 02, 2025 - and confidentiality do not exist, that reporting systems are not burdensome to use, that reported events … Challenges of reporting quickly give rise to challenges of encoding and organizing the adverse event … Strategies and efforts aimed at adverse event surveillance, creating useable taxonomies, and addressing … Another paper examines the perceptions of health care leaders and news media professionals related to adverse … Risk is treated by safety scientists as the likelihood that exposure to a hazard will lead to adverse

328. Improving Communication and Teamwork in the Surgical Environment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-slide-set.pptx
     May 01, 2017 - and/or medical errors Report on safety events after the fact 5Maurer M, Dardess P, Carman, KL, et al … events, compliance with patient privacy laws 4Advancing the Practice of Patient- and-Family-Centered … , to Responding to Adverse Events). … Organizations should be prepared to respond and communicate proactively when adverse events occur. … , to Responding to Adverse Events).

329. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Of the preventable adverse drug events in nursing homes, 70 percent occurred at the monitoring stage … The FDA COSTART categories provide standard dictionary terminology to classify reported adverse events … One-third of preventable adverse drug events were neuropsychiatric (including delirium, hallucinations … Epidemiology of adverse drug events in the nursing home setting. Drugs Aging 1995;7:203–11. 17. … Incidence and preventability of adverse drug events in nursing homes.

330. Making Health Care Safer II, Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
     March 01, 2013 - drug events, or pressure ulcers. … In contrast, events an order of magnitude or more lower in frequency were considered “rare;” such events … Practices Designed for a Specific Patient Safety Target Adverse Drug Events High-alert drugs: patient … ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090.

331. Strategy 4: IDEA Discharge Planning (Tool 3) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
     January 01, 2010 - engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.

332. AHRQ Safety Program For Long-Term Care: CAUTI
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
     March 01, 2017 - HAIs/CAUTI Long-Term Care Safety Modules Teamwork and Communication | ‹#› 27 Communicating Adverse … Events Adverse event: An injury to a resident caused by medical intervention rather than by the underlying … The mission of frontline care providers is to help and care for residents without harming them, but adverse … events happen  When an adverse event occurs, it can be difficult for a care provider to take ownership … Outcomes Immediate Response to an Adverse Event Next Steps in Responding to an Adverse Event Care

333. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - analyses (RCA) that examine systems issues and identify mechanisms for future prevention of these events … events.1 The subcommittee adopted the NCC MERP definition of a medication error:5 Analysis of … events. … Identification and classification of the causes of events in transfusion medicine. … Leape LL, Bates DW, Cullen DJ, et al., Systems analysis of adverse drug events.

334. Patient Safety Organizations Program | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
     November 01, 2024 - the creation of PSOs and the development of Common Formats for uniform reporting of patient safety events … external experts who can assist providers in the collection, analysis, and aggregation of patient safety events … access to Common Formats (uniform definitions and reporting formats for collecting information about adverse … events).

335. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - previously undetected adverse events. … The incidence and severity of adverse events affecting patients after discharge from the hospital. … The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice study … Incidence of adverse events and negligence in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

336. Patient and Family Engagement in the Surgical Environment Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-slides.html
     May 01, 2017 - Help prevent specific safety events and/or medical errors. … Report on safety events after the fact. … Fear of litigation Transparency and adverse events, compliance with patient privacy laws. … Organizations should be prepared to respond and communicate proactively when adverse events occur. … , to Responding to Adverse Events).

337. Infographic - New AHRQ Report Compares Early Stage Breast Cancer Radiotherapy Approaches (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
     June 02, 2025 - Cancer-Free Survival Outcomes Similar at 5 and 10 Years Whole Breast Irradiation (WBI) Acute Adverse … Events Were Significantly Fewer With PBI Compared With WBI Partial Breast Irradiation (PBI)

338. Eliminating Preventable Harms During Pediatric Intubation | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
     July 01, 2025 - These adverse events are influenced by patient, provider, and practice factors. … Both the video laryngoscope and apneic oxygenation interventions resulted in reductions in adverse … events and continue to be used throughout the NEAR4KIDS network of pediatric ICUs. 

339. PowerPoint Presentation (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/manage-resident-UTI-slides.PPT
     June 01, 2021 - not associated with increased morbidity or mortality Unnecessary antibiotics are associated with: Adverse … Events/Notes TMP-SMX (Bactrim) Oral Concentrates in urinary tract Hyperkalemia, rash, warfarin interaction … Events form and encourage staff to use this when a resident was harmed or had the potential to be harmed … of Antibiotic Decision Making Form Monthly Data Collection Form Learning From Antibiotic-Associated Adverse … Events 23 UTI Management 23 Disclaimer The findings and recommendations in this presentation

340. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
     October 01, 2017 - events? … events Through a noninvasive interface after HMV, BPAP, or CPAP Patients with chronic respiratory … (KQ 5) Adverse Events using the “CBK” approval code and home BPAP machines using the “MNT” and “ … These physiologic aberrations may result in several adverse outcomes that include, but are not limited … events Timing • At least 1 month of treatment Setting • Home • Assisted living residence