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Showing results for "adverse events".
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521. Medication Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/interventions/medmanage-slides.html
     May 01, 2017 - Adverse drug events result in as many as 4.5 million ambulatory visits each year. 1 Medication reconciliation … improves patient safety and reduces adverse drug events: prescribing errors, medication contraindications … Adverse drug events in U.S. adult ambulatory medical care.

522. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - An event that causes harm is typically called an adverse event (e.g., retained surgical instrument); … However, 2 definitions of events vary widely, and determining a population at risk for most events … Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical … Reporting of adverse events. N Engl J Med 2002; 347: 1633-1638. 6. … Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051-1056. 19.

523. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Thromboembolism 0 414 Medication Safety 126 416  -- Medication Errors/Preventable Adverse … Drug Events 96 420  ---- Administration Errors 14 419  ---- Dispensing Errors … Ordering/Prescribing Errors 6 418  ---- Transcription Errors 5 415  -- Side Effects/Adverse … -- Governmental Reporting 1 622  ---- Institutional Reporting 2 690  ---- Never Events … Robotic-Assisted Surgery 0 665  ---- Computer-Assisted Radiotherapy 0 661  -- Computerized Adverse

524. IV. Evaluation Aims, Methods, and Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/eval4.html
     May 01, 2016 - conducted, what contributing factors were identified, whether a matching report was found in the staff adverse … For comparison, spontaneous reporting from hospital-based adverse event reporting systems for health … n The term “negative effect” tested well in focus groups and cognitive testing, in contrast to “adverse … The system distinguishes between adverse events that are preventable, adverse events that are not preventable … q An “adverse event” in the IOM classification system is equivalent to an “incident” in the AHRQ Common

525. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Schillinger.pdf
     January 01, 2004 - Because oral anticoagulants are associated with preventable adverse events at disproportionately high … events,4, 37 such as thrombotic events (under-treatment) or bleeding (over- treatment). … events are common18 and warfarin is involved in preventable adverse drug events at rates disproportionate … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse drug events in ambulatory care. NEJM 2003 348(16):1556– 64. 19.

526. Chapter 2. ST-PRA Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
     April 01, 2018 - It utilizes both quantitative and qualitative data to "map" the risks associated with adverse outcomes … interact with one another and either individually or collectively combine to contribute to the overall adverse … Is proactive, identifying the possible adverse events before they actually occur, thus enabling the decision … modeling of complex interactions and dependencies among the multiple risk points that may lead to the adverse … this approach is determining the probabilities associated with human breakdowns that contribute to adverse

527. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
     May 01, 2023 - events and close calls. … These organizations consistently minimize adverse events despite carrying out intrinsically complex … Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primers/primer … /23 A growing evidence base supports specific strategies to prevent adverse drug events (ADEs). … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

528. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - Forty-five percent of the errors had adverse consequences. … events. … Confronting an adverse medical event collaboratively helped both patients and providers with patients … Patient perspectives of patient--provider communication after adverse events. … Adverse events in primary care identified from a risk- management database.

529. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pptx
     January 01, 2006 - The QIs are a set of indicators for adverse events that patients may experience as a result of an inpatient … Indicators (PSIs), Inpatient Quality Indicators (IQIs), Pediatric Quality Indicators (PDIs) QIs represent events … 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

530. Information to Help Hospitals Get Started (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pdf
     June 02, 2025 - Research shows patient-centered communication can improve: – Patient safety • More than 70% of adverse … events caused by breakdowns in communication – Patient outcomes, including emotional health, functioning … • Nearly 20% of patients experience an adverse event within a month of discharge, of which ¾ could be … prevented • Common complications post-discharge are adverse drug events, healthcare-associated infections

531. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
     August 01, 2022 - The project team noted that approximately half the failures associated with these four adverse obstetric … outcomes were common to all four events, suggesting that that “multiple events may be mitigated by the … events. … These adverse events are relevant because obstetric and perinatal-related claims are among the most frequent … An ACEx2 program differs from other disclosure and offer models “because it focuses on adverse events

532. Understand the Science of Safety Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
     July 01, 2018 - 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.

533. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
     July 01, 2018 - suffer a medication error 2 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.

534. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Finally, RCA often directs its focus on events that are among the most serious, while ignoring events … outcomes: The last link in a chain of events. … An alternative strategy for studying adverse events in medical care. … The critical care study: The incidence and nature of adverse events and serious medical errors in intensive … Surveillance of medical device-related hazards and adverse events in hospitalized patients.

535. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
     March 01, 2017 - Slide 28: Communicating Adverse Events Say: Communication following an adverse event can been especially … Each facility has policies and procedures to follow after an adverse event occurs, and most involve working … Slide 30: How To Communicate About An Adverse Event Say: It is important to remember that residents … and family members can experience a number of emotions when an adverse event occurs, so communication … about an adverse event should be compassionate and sensitive.

536. Final Progress Report: Transforming the Medication Regimen Review Process of High-Risk Drugs Using a Patient-Centered, Telemedicine-Based Approach to Prevent ADEs in the Nursing Home (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/kane-gill-report.pdf
     January 01, 2024 - A recent Office of Inspector General (OIG) report estimated that 37% of all harmful adverse events are … Our prior work confirmed the frequent occurrence of hypoglycemic events in NHs (9.5 events per 1,000 … Post-admission Alerts Evaluated for Adverse Drug Events Telemedicine Communications. … Adverse drug events were defined as injuries resulting from a medication. … drug events in the nursing home.

537. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
     January 01, 2024 - drug events (ADEs) that result in injury or death, and the costs of such events are estimated to total … Incidence and preventability of adverse drug events among older persons in the ambulatory setting. … Adverse outpatient drug events--a problem and an opportunity. N Engl J Med 2003; 348:1587-9. 18. … Impact of basic computerized prescribing on outpatient medication errors and adverse drug events. … Adverse drug events in ambulatory care.

538. 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.

539. 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

540. 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