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361. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - clinician attitudes about the disclosure of individual, team, and system failures associated with four adverse … members tended to agree on which system failures were important to disclose, regardless of the type of adverse … Clinician responses were more varied and were affected by type of adverse event, but they did agree with … events, and conducting clinical safety interventions. … transitioning from hospital to home care to determine the potential for discrepancies to result in an adverse

362. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - suffer a medication error2 On average, every patient admitted to an intensive care unit suffers an adverse … Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34. … An alternative strategy for studying adverse events in medical care.

363. Major Hospital Quality Measurement Sets | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/measures/setting/hospitals/measurement-sets.html
     February 01, 2023 - The Patient Safety Indicators (PSIs) identify adverse events occurring during hospitalization. … They provide information on potential in-hospital complications and adverse events following surgeries

364. Disclosure Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
     August 01, 2022 - Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an adverse … Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.   … Be honest EXPLAIN the facts about the adverse event without the patient having to do a lot of probing

365. Mod5-Disclosure-Checklist (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
     April 01, 2016 - ■ Within 60 minutes after the CANDOR event is identified, advise the patient and/or family that an adverse … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize ■ Say you are sorry for the adverse event in a sincere manner early in the conversation.

366. Appendix A. Flow Chart for Implementing Universal Decolonization | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apa.html
     September 01, 2013 - Safety and Adverse Events

367. Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/antibiotic-use/ambulatory-care/best-practices/uti.html
     September 01, 2022 - Recommend empiric treatment options for UTIs that are effective and minimize adverse events.

368. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - Clinical inertia is, therefore, a leading cause of potentially preventable adverse events, disability … Clinical inertia leads to adverse events just as surely as erroneous injections of certain medications … events caused by overuse or misuse of therapies, and adverse events attributable to clinical inertia … In hospital settings misuse of a therapy may lead to adverse events in minutes to hours. … Thus, clinical inertia in diabetes care may lead to several hundred thousand serious adverse events,

369. Care for the Caregiver Program Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
     August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … What type of organizational response plan is available for serious patient safety events? … clinical events? … Does your facility review patient safety events openly and share lessons learned? … YES  NO       Adverse Event Investigation Process Is an adverse event policy in place

370. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
     January 01, 2025 - We hypothesize that most of these adverse events could be prevented by designing a system to accomplish … It is hypothesized that most of these adverse events could be prevented if a system that worked for … events. … Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995; 274: 35-43. 10. … The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors

371. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/preface.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 … Transitional Care Medication Safety: Stakeholders' Perspectives Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home Since the Institute of Medicine

372. Identifying Targets for Improvement in Antibiotic Decision Making (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-facilitator-guide.pdf
     November 01, 2019 - Events? … from a diverse group of health care workers about issues that have resulted in antibiotic-associated adverse … events or had the potential to cause adverse events that could jeopardize patient safety. … Four Moments each time an antibiotic course is prescribed is one example of an antibiotic- associated adverse … In fact, the analysis shows that overall, patients were spared from adverse events associated with

373. Risk of Concurrent Use of Prescription Drugs with Herbal and Dietary Supplements in Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Graham_77.pdf
     March 05, 2008 - An observational study showed that herbal supplements are associated with adverse events of all levels … Adverse Drug Events Among Herbal and Dietary Supplement Users Twenty-nine (29 percent) of the 101 HDS … Adverse events associated with dietary supplements: An observational study. … Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556-1564. 15. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention.

374. Theodoro, Daniel | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumtheo.html
     October 01, 2014 - the location of the subclavian vein is feasible and improves patient safety by minimizing immediate adverse … events. … Model economic costs of adverse outcomes of central venous cannulations in ED.

375. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Drug Events: Examination of a Hospital Incident Reporting System (   PDF , 287 KB) Radhika Desikan … Hackworth Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs (   PDF , 172 KB) Dustin … Masheter, Paul Hougland, Wu Xu Surveillance of Surgery-related Adverse Events in Missouri Using ICD … Events Following Immunization (   PDF , 277 KB) Katrin S. … Events in Health Care (   PDF , 197 KB) Kenneth W.

376. Final Progress Report: Videotaping communication between physicians and nurses: A methods study (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/manojlovich-report.pdf
     January 01, 2024 - Breakdowns in communication between physicians and nurses continue to be a primary contributor to adverse … interdisciplinary teams4 and checklists.5 The lack of progress in preventing communication-related adverse … associated with communication between physicians and nurses outside of specialty units, despite the adverse … Incidence and Prevalence Breakdowns in communication remain one of the most common causes of adverse … events for hospitalized patients1,12,13 and a major root cause of all sentinel events reported to

377. Using Technology to Alert Clinicians to Potential Allergy, Drug Interactions | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-zhou.html
     July 01, 2024 - prominent patient safety researcher who has investigated how information technology can be used to prevent adverse … drug events. … “Drug allergy is a major type of adverse drug reaction, and it has great impact on quality of care and … Hospital Grantee Since: 2009 Type of Grant: Various Related AHRQ Resources Medication Errors and Adverse … Drug Events Medication Safety Consistent with its mission, AHRQ provides a broad range of extramural

378. Acute Care Behavior Change Theory for Antibiotic Stewardship Leaders
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
     November 01, 2019 - are different Desire for autonomy Difficulty perceiving the association between antibiotic use and adverse … events Not paying attention or not interested System challenges: inadequate communication, difficulty … are different2 Desire for autonomy Difficulty perceiving the association between antibiotic use and adverse … events Not paying attention or not interested System challenges: inadequate communication, difficulty … 90% 88% Adverse events More adverse events with longer therapy!

379. Module 1: PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview.pptx
     May 01, 2017 - An analysis of risk factors and adverse events in ambulatory surgery. … An analysis of risk factors and adverse events in ambulatory surgery. … Visual Management • Outcomes over time • Checklist compliance • Problem log Escalation • Sentinel events

380. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
     January 01, 2024 - Until recently, knowledge about the number and types of errors and adverse events occurring within the … of high- stakes conditions, with very little data available regarding the epidemiology of errors and adverse … events (AEs) within the ED. … evaluate the effectiveness of the tool, with the main outcome measure being the number of errors and adverse … monitor patient after admin Other Not available in ED Not available in pharmacy Allergic reaction/adverse