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www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/trauma.html
April 01, 2016 - Individual trauma results from an event, series of events, or set of circumstances that is experienced … by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse … [i]
Exposure to traumatic events in the lives of women such as Intimate Partner Violence (IPV) , Military … systems function according to at least four basic principles:
1) Realize the prevalence of traumatic events … Control : Division of Violence Prevention: ACE Study http://www.cdc.gov/violenceprevention/acestudy
The Adverse
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www.ahrq.gov/research/findings/studies/index.html?page=368
January 01, 2024 - Keywords: Adverse Drug Events (ADE), Brain Injury, Intensive Care Unit (ICU), Medication, Trauma … Keywords: Adverse Drug Events (ADE), Diabetes, Medication, Patient-Centered Healthcare, Risk … Keywords: Adverse Events, Antimicrobial Stewardship, Education: Patient and Caregiver, Ambulatory Care … Keywords: Adverse Events, Patient Safety, Health Information Technology (HIT)
Brown SD , Ehrlich … Keywords: Adverse Drug Events (ADE), Blood Thinners, Data, Diagnostic Safety and Quality, Medication
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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
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www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
January 01, 2024 - events.13
Second, disinterest to date in pursuing such activities has generally been mutual: the
principal … However, a vital step toward progress in this area is the marshalling of detailed
information on such events … Outcome
Clinical
Category
- Kappa for adverse events: 0.38 - 0.42 (intermediate)
- Kappa for … Pre-eclampsia
Missed breast
cancer
Outpatient
events
Descriptive
Analyses
Case-Control … Relation between malpractice claims and adverse
events due to negligence.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14283-Dresselhaus-draft-1.pdf
September 29, 2005 - Medication errors, including preventable adverse drug events, are especially common in the
inpatient … A computer alert system to
prevent injury from adverse drug events: development and evaluation in a … Drug Events
Data Sources & Measures. … events. … Although most of the adverse drug events that occur during the
study period will be linked to a specific
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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
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www.ahrq.gov/sops/events/webinars/just-culture/presentation.html
January 01, 2017 - Policies; Corrective Action, Sentinel Events, Adverse Event Reporting.
Patient Safety Plan.
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www.ahrq.gov/es/hai/patient-safety-resources/advances-in-hai/hai-article19.html
June 01, 2014 - It utilizes quantitative and qualitative data to "map" the risks associated with adverse outcomes. … points interact with one another and either individually or collectively combine to contribute to the adverse … is determining the probabilities associated with breakdowns in human performance that contribute to adverse … Is proactive, identifying the possible adverse events before they actually occur, thereby enabling the … Models complex interactions and dependencies among the multiple risk points that may lead to the adverse
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www.ahrq.gov/hai/patient-safety-resources/advances-in-hai/hai-article19.html
June 01, 2014 - It utilizes quantitative and qualitative data to "map" the risks associated with adverse outcomes. … points interact with one another and either individually or collectively combine to contribute to the adverse … is determining the probabilities associated with breakdowns in human performance that contribute to adverse … Is proactive, identifying the possible adverse events before they actually occur, thereby enabling the … Models complex interactions and dependencies among the multiple risk points that may lead to the adverse
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … This video demonstrates an example of emotional support provided for the physician caregiver after an adverse
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www.ahrq.gov/patient-safety/settings/hospital/candor/videos/nurses.html
August 01, 2022 - institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … This video demonstrates an example of emotional support provided for the nurse caregiver after an adverse
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www.ahrq.gov/research/findings/studies/index.html?page=320
January 01, 2024 - Keywords: Adverse Drug Events (ADE), Children/Adolescents, Disabilities, Medication, Patient Safety … Meaningful use of health information technology and declines in in-hospital adverse drug events. … Keywords: Health Information Technology (HIT), Electronic Health Records (EHRs), Adverse Drug Events … Keywords: Medication, Guidelines, Diabetes, Adverse Drug Events (ADE)
Chandakkar PS , Venkatesan … Keywords: Adverse Drug Events (ADE), Diabetes, Medication, Risk
Loucas CA , Brand SR , Bedoya
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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
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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.
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www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/findings.html
May 01, 2016 - 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
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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.
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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.”
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/11835-Lapane-draft-1.pdf
January 01, 2006 - 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.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/common-cold-guide.docx
September 01, 2022 - Harm associated with antibiotics includes adverse drug events, microbiome disruption, and antibiotic … Adverse drug events from antibiotics are very common. … Patients are four times as likely to require an emergency department visit for an adverse event related … events from the medications should be taken into consideration before recommending them to individual … In fact, they could lead to an adverse event, like diarrhea, that could make it harder to participate
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - management
Disruptive behavior and/or code of conduct
Investigation of occurrences (i.e., sentinel events … Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse … or "harm" events
___
___
Organizational safety and/or quality plan
FMEAs