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Showing results for "adverse events".
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381. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
     March 21, 2008 - Among a sample of elderly patients, Gurwitz, et al.,6 found that many adverse drug events were due to … adverse events or recovery transactions are recorded. … Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556-1564. 3. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Classification of medical errors and preventable adverse events in primary care: A synthesis of the

382. Appendix B. Search Terms | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appb.html
     March 01, 2017 - Patient safety Safety Safety culture Safety climate Medical error Disclosure Adverse … events Just culture Error reporting Reporting culture Communication Error Harm

383. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
     January 01, 2004 - They could be adverse events (events resulting in unintended harm) or near misses (events that had the … Reporting of adverse events. NEJM 2002;347:1633–8. 3. Green L, Fryer G, Yawn B, et al. … Adverse events in primary care identified from a risk-management database. … Reporting of adverse events (correspondence). NEJM 2003;348:1410–1. 19. Ehman A. … Issues in the reporting of adverse healthcare events.

384. Final Progress Report: Risk-Informed Clinical Network for Safe Pediatric Emergency Transfers (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods-report.pdf
     January 01, 2025 - adverse events occurred during the 16-month data collection period (n=106), representing a 32% adverse … in 14% of the transfers (44% of the adverse events). … Ambulatory care adverse events leading to a Hospital Admission. … Adverse Events and PreventableAdverse Events in Children. Pediatrics. … Medication errors and adverse drug events in pediatric inpatients.

385. TeamSTEPPS Research/Evidence Base: Labor and Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/evidence-base/labor.html
     May 01, 2023 - Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events … Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized … Impact of a comprehensive patient safety strategy on obstetric adverse events. 

386. Minding the Gaps: Creating Resilience in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
     April 27, 2008 - As an emergent property of systems that is not tied to tallies of adverse events or estimates of their … Hollnagel2 has suggested that our understanding of adverse events and their causes evolves through … In the 1960s, technology and equipment were often cited as the attributable cause of adverse events. … As an emergent property of systems, resilience is not tied to tallies of adverse events or estimates … As far as is known, no adverse events were associated with this episode.

387. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - system is in place for reporting all adverse events and near misses. … Design and implementation of comprehensive and accessible systems for adverse events reporting from … Systems analysis of adverse drug events. ADE Prevention Study Group. … Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and … The nature of adverse events in hospitalized patients.

388. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - Exploring relationships between hospital patient safety culture and adverse events. … Beliefs, behaviors reflect organizational ability to learn Associated with adverse events, patient satisfaction … Exploring relationships between hospital patient safety culture and adverse events. … events. … Reported Frequency of Events Reported Frequency of Events Reported Supervisor Manager Actions Promoting

389. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
     May 01, 2016 - events. … drug events. … events. … These adverse events are relevant because obstetric and perinatal-related claims are among the most … An ACEx2 program differs from other disclosure and offer models “because it focuses on adverse events

390. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - events. … drug events. … events. … These adverse events are relevant because obstetric and perinatal-related claims are among the most … An ACEx2 program differs from other disclosure and offer models “because it focuses on adverse events

391. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap4.html
     December 01, 2014 - 2014 Goal Met Projected Reductions in Deaths Associated With HACs in 2014 if 2014 Goal Met Adverse … Drug Events 1,900,000 50% 50% 25% 475,000 $5,000 .020 $2,375,000,000 9,500 Catheter-Associated … Falls 200,000 25% 50% 12.5% 25,000 $7,234 .055 $180,850,000 1,375 Obstetric Adverse … Events 380,000 30% 50% 15% 57,000 $3,000 .0015 $171,000,000 84 Pressure Ulcers

392. Final Progress Report: Pharmacist Technology for Nursing Home Resident Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
     January 01, 2024 - Heightened awareness of adverse drug events may have occurred in the intervention homes. … Trends in decreases in hospitalizations due to serious adverse events were observed but did not reach … The prevention of adverse drug events. ECPN 2005;June:26-32. Feinberg JL. … Incidence and preventability of adverse drug events in nursing homes. … A computer alert system to prevent injury from adverse drug events. JAMA 1998; 280: 1317-1320.

393. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
     January 01, 2017 - Healthcare-Acquired Conditions (HACs) Series 1 VAPs SSIs CLABSI Other HACs Pressure Ulcers Post-op DVTs Falls Adverse … Drug Events Obstetric Adverse Events CAUTI 21001 21000 17000 17000 17000 8000 7234 5000 3000 1000 … Descriptive epidemiology and attributable morbidity of ventilator-associated events. … 17,000 Other HACs $ 17,000 Pressure Ulcers $ 17,000 Post-op DVTs $ 8,000 Falls $ 7,234 Adverse … Drug Events $ 5,000 Obstetric Adverse Events $ 3,000 CAUTI $ 1,000

394. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - after a serious wrong-side surgery event at a New York hospital in 2005 and a review of recent NYPORTS adverse … assembled to review the data derived from the RCAs, identified commonalities in the causes of the adverse … well as multiple contributing factors (e.g., “environmental conditions” increasing the chance of the adverse … Flink, E, Chevalier, EC, Ruperto, A, et al., Lessons learned from the evolution of mandatory adverse … Wrong-side/wrong-site, wrong- procedure, and wrong-patient adverse events: Are they preventable?

395. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - Grant Award Number: 5U18HS011926-03 Abstract Purpose: Adverse events are among the nation’s most … Scope Preventable adverse patient events, including nosocomial or hospital-acquired infections and … The Institute of Medicine reports that adverse patient events are responsible for 44,000-98,000 deaths … events. … Adverse Drug Events (ADEs), which can result from a medication error, occur at a rate of 2.4% to 4.6%

396. Final Progress Report: Safety Outcomes of Obese Residents in US Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
     January 01, 2024 - safety events. … safety events. … Rates of Adverse Safety Events by BMI Category Fa lls Fa lls w ith in ju rie s Pr es su re … In fact, across the adverse safety events, we found that obesity was actually a protective factor for … Thus, it was unexpected that for-profit NHs had lower adverse events among their residents with obesity

397. Measure Descriptions for Daily Early Mobility: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/daily-early-mobility-slides.html
     February 01, 2017 - Adverse events. Event types. … Slide 29: Events Image: Detail of the event reporting column from the data collection tool. … Can include up to three events if necessary. … Adverse event incidence rate (intubated and non-intubated). … Top 10 adverse events for ventilated and nonventilated patients.

398. Comparing Quality Scores to an Independent Standard | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
     January 01, 2023 - The Standard for “Never Events” There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”

399. Module 1 Implementation Guide: Welcome to the TAKEheart Initiative and an Overview of the Benefits of Increasing Cardiac Rehabilitation Participation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-implementation-guide.pdf
     January 01, 2018 - o CR reduces mortality over 1-3 years after a cardiac event o CR reduces re- hospitalization and adverse … events, such as subsequent MI o CR can help patients with medication adherence, and management of multiple … chronic conditions, diabetes, depression, mental stress and improves quality of life after an adverse … events - CR reduces morbidity and mortality and improves quality of life -CR reduces avoidable … events – which are metrics tracked and incentivized by payers o Review the information presented

400. Final Progress Report: Encoding and Processing Patient Allergy Information in EHRs (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/zhou-report.pdf
     January 01, 2024 - Obtaining allergy information is a critical step toward safe prescribing, preventing adverse drug events … Adverse events from medications are part of clinical practice, but the ability to identify a patient's … The ability to identify adverse events has been a challenge due to limitations of available data sources … events for postmarketing surveillance, such as those posted on social media that would otherwise go … for specific adverse events at the time of medication prescription or review.