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Showing results for "adverse events".
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501. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
     February 24, 2008 - Introduction Public and professional concern over patient safety, adverse health care events, and medical … Lucian Leape on the causes and prevention of errors and adverse events in health care. … Preventing adverse drug events. Am J Health Syst Pharm 1995; 52: 379-382. 6. Leape LL. … The nature of adverse events in hospitalized patients. … Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.

502. Pf-Engagement-Facnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-facnotes.docx
     May 01, 2017 - This can help prevent safety events and/or medical errors. … Fear of Litigation With patient privacy laws and the fear of oversharing information about adverse events … Report to appropriate parties – Providers will use their facility’s policies to report adverse events … Communication about adverse events is a delicate process that requires collaboration with and guidance … Organizations should be prepared to respond and communicate proactively when adverse events occur.

503. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     June 02, 2025 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … when something does not seem right .... 1 2 3 4 5 SECTION D: Frequency of Events … Management in this facility seems interested in patient safety only after an adverse event happens … facility ........................... 1 2 3 4 5 SECTION G: Number of Events … Safety Grade SECTION F: Your Facility SECTION F: Your Facility (continued) SECTION G: Number of Events

504. Final Progress Report: Training Doctors To Disclose Unanticipated Outcomes to Patients: Randomized Trial (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/gallagher3-report.pdf
     January 01, 2024 - UW had 68 qualifying events reported and 22 non-qualifying events. … surveys were received back from nearly 50% of the patients and over 90% of the physicians, and no adverse … In this and many other projects, physician fear of the consequences of adverse event reporting and lack … The disclosure dilemma: Large scale adverse events. NEJM 2010;363(10)978-986. 5. … Patient experiences of a large scale adverse event. In press, Journal of Clinical Ethics.

505. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - Adverse event reports of falls and medication errors were analyzed to evaluate the value of tools for … Key Words: patient safety, medical errors, reporting, adverse events, disclosure 3 Overall Purpose … Anticoagulation Monitor Methods: The Anticoagulation Monitor was developed to reduce adverse drug events … Language Processing Methods: Test the potential of Natural Language Processing technology to detect adverse … Reporting of adverse drug events: Examination of a hospital incident reporting system.

506. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
     May 01, 2017 - 3 SAY: Further, EFM interpretation and management is a common issue in litigation involving adverse … individual staff skills with respect to EFM interpretation may not be enough to reduce perinatal safety events … Perinatal Care Electronic Fetal Monitoring 8 SAY: A unit can decide its approach to debriefing events … events. … • Past adverse events related to EFM use. • Synergy with related or similar initiatives (e.g., initiatives

507. Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
     January 01, 2014 - 2.1 MILLION 2.1 MILLION From 2010–2014, 17 percent of hospital-acquired conditions (HACs) such as adverse … drug events, healthcare-associated infections, and pressure ulcers have been prevented in hospital

508. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - Post-fielding surveillance, akin to post-marketing surveillance for adverse events, may detect rarely … due to rare events in data extraction and conversion from the electronic health record. … outcomes, especially when the events are rare. … events data. … percent) feedback comments, investigation revealed 4 distinct problems in clinical data due to rare events

509. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - We do know, however, that medical errors and preventable adverse events occur in ambulatory primary … The incidence of preventable errors or adverse events in primary care is high, and evidence suggests … Adverse events in primary care identified from a risk- management database.[see comment]. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse outpatient drug events--a problem and an opportunity.[see comment][comment].

510. Final Progress Report: Detecting, Assessing, and Learning from Patient-Perceived Breakdowns in Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/mazor-report.pdf
     January 01, 2024 - A major emphasis in patient safety has been encouraging reporting of adverse events and errors by healthcare … For example, Weissman and colleagues found that patients frequently knew of adverse events and errors … Yet, there is good reason to believe that many patients who experience adverse events and errors may … Other patients, however, may accurately perceive care breakdowns, including adverse events. … Comparing patient-reported hospital adverse events with medical record review: do patients know something

511. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
     October 01, 2023 - Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Her team found that 10 percent of children with leukemia or lymphoma experienced adverse drug events

512. History and Funding of PBRNs | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/communities/pbrn/history/index.html
     November 01, 2024 - science base of clinical care through systematic inquiry to better understand the health and health care events … PBRN Web Events —PBRN researchers, directors, and staff participate in ongoing discussions dedicated … pandemic influenza event. 7   Field testing of a new ambulatory care electronic Medication Errors and Adverse … Drug Events Reporting System (MEADERS). 8 References Lanier D. … Field test results of a new ambulatory care Medication Errors and Adverse Drug Events Reporting System

513. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
     January 01, 2024 - Usability events were grouped into thematic categories: navigation/UI events, health literacy events … Adverse drug events and medication errors in Australia. … Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting. … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between Hospital

514. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c3_pdi_staffpresentation.pptx
     January 01, 2006 - events that children, adolescents, and, where specified, neonatal patients may experience as a result … PDIs measure events likely to be preventable through changes at the system or provider level. … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … on: Comparison between our hospital and peer hospitals Our performance over time Volume and cost of events … You may also want to report the number of patients with the adverse event to make it more tangible to

515. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
     September 01, 2016 - in the past 12 months, and about respondent perceptions of the frequency of events reported. … Watson Senior Vice President Michigan Health & Hospital Association 3 of adverse events and discussion … offers a way for PSO members to share accounts of patient safety events. … The alerts describe the reported events and provide information on how to prevent similar events. … Exploring relationships between hospital patient safety culture and adverse events.

516. National Action Plans | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/national-action-plans.html
     February 01, 2018 - National Action Plan for Adverse Drug Events identifies the Federal Government’s highest priority strategies

517. Client Functioning Measures and Gaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/rep3.html
     June 01, 2010 - Regardless, all programs strive to promote optimum client health and avoid preventable adverse health … promotion ix and the receipt of recommended health care services, but also the avoidance of serious adverse … In particular, the adverse relationship between disability and employment has been well established. … These include serious, reportable events that reflect a consensus regarding client health and safety, … Consistency and consensus are lacking with regard to HCBS-appropriate definitions of serious reportable events

518. Learning from Errors in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
     February 01, 2004 - drug events and preventable adverse drug events) occurred at a three-fold higher rate in children than … Incidence of adverse drug events and potential adverse drug events: implications for prevention. … Adverse drug events in hospitalized patients. JAMA 1997;277:301– 6. 3. … Medication errors and adverse drug events in hospitalized children. … Adverse sedation events in pediatrics: a Critical Incident Analysis of contributing factors.

519. Prologue—Volume 1—Five Years Later—Are We Any Safer? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
     January 01, 2004 - the initial IOM goal for some injury sources (for example, Brigham & Women’s Hospital in Boston for adverse … drug events [ADEs]; Intermountain Health Care’s LDS Hospital in Salt Lake City for ADEs and for postoperative … injuries, and near misses, because of difficulties in recognizing, tracking, and summarizing these events … trigger systems), to successful interventions that addressed specific, single injury sources (e.g., adverse … drug events), to organizational structures (e.g., building a culture of safety; nursing roles; teamwork

520. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
     January 01, 2023 - and is defined as harm to the patient after discovery of the incident and any attempts to minimize adverse … For example, Medication or Other Substance events that were reported as Adverse reaction in patient … extent of harm to the patient after discovery of the incident and after any attempts to minimize adverse … extent of harm to the patient after discovery of the incident and after any attempts to minimize adverse … decision to prescribe medication despite known drug-drug interaction) • Drug-drug, drug-food, or adverse