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401. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Scope and Significance Preventable Adverse Drug Events in Community Pharmacies Adverse drug events (ADEs … The cost of adverse drug events in hospitalized patients. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Adverse drug events in hospitalized patients. … Adverse drug events in ambulatory care.

402. 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

403. Suggested Timeline for Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/timeline-tasks.pdf
     June 01, 2021 - Events Form Four Moments of Antibiotic Decision Making Form Completion Guide for the Four Moments … Events Form Review the Staff Safety Assessments and identify common problems, themes, or ideas … Events Form and encourage staff to use this when a resident was harmed or had the potential to be … Events forms (from weeks 8 and 14) to identify problems • Discuss problems and identify another … Monthly • Learning From Antibiotic Adverse Events Form. Discuss quarterly.

404. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
     March 01, 2020 - Reducing Adverse Drug Events in Older Adults: Deprescribing Drug burden index scores Adverse … Reducing Adverse Drug Events in Older Adults: Using the Screening Tool of Older Persons’ Potentially … Infusion Pumps/Medication Error : Staff Education and Training Adverse drug events Nurse adherence … Cross-Cutting Factors: Safety Culture Leadership WalkRounds Adverse events Perceptions … Use of the checklist was associated with a decrease in adverse events.

405. 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

406. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
     May 01, 2017 - Professional Liability EFM interpretation and management are a common issue in litigation involving adverse … events, and the contribution of EFM use, EFM interpretation, and communication of EFM findings. … Have a process in place to review severe maternal or neonatal morbidity and mortality events. … events 17 AHRQ Safety Program for Perinatal Care Electronic Fetal Monitoring 17 Unit Next Steps … Past adverse events related to EFM use Synergy with related or similar initiatives Interest and enthusiasm

407. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa2.pdf
     January 01, 2018 - events in adults receiving knee replacement -12.31 0.0 0.014 MPSMS 8 (2009- 2016) Hospital patients … Xa -11.33 0.0 0.00 MPSMS 8 (2009- 2016) Inpatient adverse events in adults receiving hip joint replacement … events in adults receiving hip joint replacement due to fracture -7.11 0.0 0.021 MPSMS 8 (2009- 2016 … ) Hospital patients who received a hypoglycemic agent who had an adverse drug events with hypoglycemic … events in adult patients receiving central venous catheter placement -3.83 0.0 0.014 MPSMS 8 (2009

408. 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

409. 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.

410. 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.

411. 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.

412. 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

413. 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,

414. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
     October 01, 2017 - Perinatal Safety 13 Key Safety Elements: Learn From Defects Debrief and analyze near misses and adverse … events, regardless of whether a rapid response was activated Debrief among clinical team after rapid … Response Call Log can facilitate a debrief Have a process in place to review serious maternal or neonatal adverse … Consider these factors: Unit data suggesting adverse events or near misses that may have been minimized … Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to

415. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-slides.pptx
     January 01, 2017 - Sedation Delirium Early mobility (EM) Perceived barriers to EM Physical/occupational therapy (PT/OT) Adverse … events Event types Early Mobility Measures ‹#› AHRQ Safety Program for Mechanically Ventilated … or ASE ≤2 (no delirium) Percentage of incorrectly reporting CAM-ICU/ICDSC/ASE UTA (Unable to Assess) Adverse … } Distribution of RASS/SAS Actual Scores Physical or occupational therapy participation rate Top 10 adverse … events for ventilated and nonventilated patients Perceived barriers for ventilated patients Early

416. 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

417. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - The relationship between process (individual errors) and safety outcomes (adverse events) is non-linear … events. … events. … Staff expressed concerns regarding the malpractice and legal ramifications of reporting adverse events … Medication errors, critical incidents, adverse drug events, and more: a review examining patient safety-related

418. 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

419. Evaluation Issues | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/issues.html
     August 01, 2022 - Others implemented patient safety interventions that plausibly might reduce the occurrence of adverse … events and thus stem the flow of subsequent claims. … AHRQ’s initial plan to require the PSML demonstration sites to collect Common Formats data on adverse … malpractice “claims tail” (i.e., that malpractice claims frequently take years from the occurrence of an adverse

420. 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.