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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
January 01, 2013 - The cost of adverse drug events in hospitalized patients.
JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care
Med 2007;35(11)2637-8.
Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the
impact of potential adverse events on outcomes. … The costs and savings associated with prevention of
adverse events by critical care nurses.
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www.ahrq.gov/research/findings/studies/index.html?page=417
January 01, 2024 - Concerns of adverse events resulting from universal glove and gown use were not supported. … The effect of universal glove and gown use on adverse events in intensive care unit patients. … Keywords: Patient Safety, Intensive Care Unit (ICU), Adverse Events, Healthcare-Associated Infections … Keywords: Children/Adolescents, Outcomes, Surgery, Adverse Events, Quality Improvement
Linzer … Keywords: Pregnancy, Adverse Events, Medication, Patient-Centered Outcomes Research, Newborns/Infants
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - For example, 2,438
Medication or Other Substance events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance
events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance
events that were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that
were reported as Adverse reaction in patient … For example, 2,438 Medication or Other Substance events that were reported as Adverse
Patient Safety
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www.ahrq.gov/patient-safety/capacity/candor/demo-program/grants/summary.html
May 01, 2016 - events that is not otherwise known to those analyzing the event. … and Communication Together (IMPACT) for eliciting patient and family perspectives on their harmful events … Team communication training
The rates of communication-sensitive adverse events (CSAEs) were examined … events in labor and delivery (increasing from 43 to 84 reports per 1,000 births). … there was no documented followup, and a 54% reduction in the rate of serious potential safety risk events
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures. … Simulations—that an L&D unit can use to teach team members how to apply CUSP to prevent obstetrical adverse … events.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
May 05, 2008 - Meliones MD, MS
Abstract
Background: During the analyses of adverse events, a commonly described … These patients are
at increased risk for adverse events because of the complexity of their diagnosis … Understanding adverse events: Human
factors. Qual Health Care 1995; 4: 80-89.
5. Reason J. … The nature of
adverse events in hospitalized patients. … Understanding and responding to adverse
events. N Engl J Med 2003; 348: 1051-1056.
16.
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www.ahrq.gov/research/findings/studies/index.html?page=332
January 01, 2024 - Keywords: Adverse Drug Events (ADE), Elderly, Medication, Patient Safety
Poghosyan L , Liu … Keywords: Cancer, Cancer: Breast Cancer, Surgery, Adverse Events, Patient-Centered Outcomes Research … It found that adverse tracheal intubation associated events and desaturations are common and associated … Relationship between adverse tracheal intubation associated events and PICU outcomes. … Keywords: Adverse Events, Children/Adolescents, Respiratory Conditions, Patient Safety, Children/Adolescents
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www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
January 01, 2024 - Medication safety issues, which
encompass both medication errors and adverse drug events, are a predominant … In other chronic disease states,
adverse drug events have been clearly established as a major risk factor … Therefore,
early recognition of adverse drug events in kidney transplant recipients will likely help … AE type and severity were defined
using the Common Terminology Criteria for Adverse Events. … Incidence and
impact of adverse drug events contributing to hospital readmissions in kidney transplant
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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.
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www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
February 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 17: Staff Safety Assessment
Say:
Adverse reporting systems, sentinel events, and claims data
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
January 01, 2018 - Safety
Tejal Gandhi
Handwriting
16
Ways IT Can Improve Safety
• Prevent errors and adverse … events
• Facilitating a more rapid response after an
adverse event has occurred
• Tracking and providing … feedback about adverse
events
Bates, Gawande 2003
Main Strategies for Preventing
Errors and AEs
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www.ahrq.gov/research/findings/studies/index.html?page=69
January 01, 2024 - Rates of adverse events in hospitalized patients after summer-time resident changeover in the United … Keywords: Adverse Events, Patient Safety, Provider: Physician
Eisenberg MT , Block AM , Vopat … childhood events: National Survey of Children's Health 2016-2017. … events: National Survey of Children's Health 2016-2017. … Keywords: Cardiovascular Conditions, Surgery, Adverse Events
Schnitzer K , Senft N , Tindle
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
January 01, 2003 - Relationship between medication errors and adverse
drug events. … Incidence of
adverse events and negligence in hospitalized patients. … drug events, and adverse drug reactions. … Adverse Drug
Prevention Study Group. The costs of adverse drug
events in hospitalized patients. … Adverse drug
events in hospitalized patients.
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www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … Comparing patient-reported hospital adverse events with medical record review: do patients know something … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review … Long-term impacts faced by patients and families after harmful healthcare events. … Health care complaints and adverse events as a means of user involvement for quality and safety improvement
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/primary-prevention-cvd-with-statins.pdf
May 10, 2018 - Articulate Word Output
Primary Prevention of Cardiovascular Disease (CVD) Events with
Statins
1 … There is no good reason to use a high-
cost brand name statin.
10 Statins: Adverse Effects … The most
important adverse effect of statins is myopathy, or muscle pain, which is reported in about … Other hypothesized adverse effects
such as memory loss have not been confirmed when they’ve been examined … On the other hand, the adverse
effects appear to be relatively independent of CVD risks.
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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.
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www.ahrq.gov/research/findings/studies/index.html?page=181
January 01, 2024 - Events (ADE), Adverse Events, Patient Safety, Intensive Care Unit (ICU), Shared Decision Making … Keywords: Cancer: Colorectal Cancer, Cancer, Surgery, Blood Clots, Adverse Events, Risk, Hospital Discharge … Keywords: Kidney Disease and Health, Medication, Medication: Safety, Patient Safety, Adverse Drug Events … (ADE), Adverse Events
Williams D , Reiter KL , Pink GH Rural hospital mergers increased … Keywords: Surgery, Ambulatory Care and Surgery, Hospital Readmissions, Hospital Discharge, Adverse Events
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
February 21, 2008 - Medical Errors and Adverse Events at Hospital Discharge
Errors and Adverse Events Are Common on Both … 49, 50
3
Adverse Drug Events: Common, Serious, and Costly
Adverse drug events (ADEs) are the … Adverse
events among medical patients after discharge from
hospital. … The costs of
adverse drug events in hospitalized patients. … Events at Hospital Discharge
Errors and Adverse Events Are Common on Both Sides of the Transition
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www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
January 01, 2024 - Key words: probabilistic risk assessment, adverse drug events, ambulatory setting
2
Purpose
In our … previous study of preventable adverse drug events among 30,000 older adults treated
in the ambulatory … setting by a multispecialty group practice over a 1-year period,1 we found a
rate of adverse drug events … of 50.1 per 1000 person-years, with a rate of 13.8 preventable
adverse drug events per 1000 person-years … Incidence and preventability of adverse drug events
among older persons in the ambulatory setting.