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www.cahps.ahrq.gov/pqmp/implementation-qi/toolkits.html
August 01, 2021 - Studies
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Events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-fullreport.pdf
February 14, 2018 - of psychiatric disorders in children,
these medications are associated with a number of potentially adverse … Fiscal Burden
Although there is little research available on the fiscal burden associated with adverse … aspect of proper medication
management in this population, as these medications are associated with adverse … Antipsychotics are associated with potentially
adverse metabolic impacts that include weight gain, diabetes … Health-care costs of pediatric clients developing adverse events during
treatment with antipsychotics
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … are on the Centers for Medicare and Medicaid Services’ list of hospital-acquired complications “never events … communication during nurse transitions, for example:
Reduce the incidence of never events by 5 percent
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
January 01, 2011 - • Sentinel events: transfusion reaction, wrong
blood type, wrong-site surgery, foreign body
left … in during procedure, medical equipment-
related adverse events, medication errors … • Other care-related adverse events: patient
falls, in-hospital hip fracture or fall
http://www.oecd.org … Hospital of Philadelphia annually reviews
all findings from root cause analyses of serious safety
events … This electronic toolbox provides States with tools
they can use or modify as they develop or improve
adverse
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix3-data-abstraction.xlsx
June 24, 2022 - utilization;
NEST_data • The specific data elements required to assess performance and outcomes (including adverse … events and their timing) in the course of the disease or treatment;
NEST_data • The appropriate settings … expectations or preferences will providers and patients be expected to have regarding benefits and adverse … NAM2019 Likelihood that beneficial or adverse effects would be reported or observed? … expectations or preferences will providers and patients be expected to have regarding benefits and adverse
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
April 27, 2022 - The remaining 2 studies
(Giardina et al29,30) analyzed existing data sets of patient reports of
adverse … events and patient complaints, respectively. … Secondary analysis of
patient reports of adverse
Timeliness, accuracy,
communication
events
( … The determination of error depends
on the temporal or sequential context of events. … Tracking Progress in improving
diagnosis: a framework for defining undesirable diagnostic events.
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www.cahps.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
October 01, 2014 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverse … events. … Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating data … During a team huddle, response team members could:
Discuss critical issues and emerging events. … and prescribe a course of action for future events.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
January 01, 2004 - our study of the impact of
working conditions of nurses on medication administration accuracy and adverse … The Safety Climate Scale focuses on organizational commitment to safety,
knowledge of how to report adverse … events, and beliefs about systems problems
as a cause of error.
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www.cahps.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/references.html
July 01, 2021 - Studies
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Events … Antipsychotic use in children and adolescents: minimizing adverse effects to maximize outcomes.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
August 01, 2010 - Nurse shift changes require the successful transfer of information between
nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused
by breakdowns in communication … on the Centers for Medicare and Medicaid Services’
list of hospital-acquired complications “never events … communication during nurse transitions, for example:
• Reduce the incidence of never events by 5 percent
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www.cahps.ahrq.gov/patient-safety/reports/advances/vol3.html
July 01, 2022 - Studies
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AHRQ Views
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About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-5.8.pdf
January 01, 2014 - survey evaluating instances of
communication with the pediatrician,
referred to as communication “events … Independent raters also coded the
communication events from videotapes. … outcomes, self-reported health,
adherence to treatment, preventive care,
health care resource use, adverse … events,
and technical quality of care. … information were obtained
from the Can Rapid Risk Stratification of
Unstable Angina Patients Suppress
Adverse
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www.cahps.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - Studies
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Events … Hospital-Acquired Conditions show that national efforts to reduce hospital-acquired conditions, such as adverse … drug events and injuries from falls, helped prevent an estimated 8,000 deaths and save $2.9 billion
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-233-fullreport.pdf
August 07, 2018 - Additional
adverse fetal effects that result in dysfunction of a formed organ or tissue include postnatal … maternal events. … We suggest availability of care is essential for women who
are at risk of adverse pregnancy outcomes … The ability to minimize
and/or prevent adverse fetal effects due to potentially teratogenic medication … Exposure to teratogens during pregnancy is
associated with significant adverse outcomes and occurs with
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www.cahps.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Studies
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AHRQ Views
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Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-fullreport.pdf
November 01, 2017 - grams per
deciliter for red cell transfusion can decrease transfusion requirements without increasing
adverse … events, ICU and
hospital LOS, mortality, and daily Pediatric Logistic Organ Dysfunction (PELOD) assessment … infection, gut ischemia, transfusion reactions, stimulation of the
inflammatory response, and other events … grams per deciliter for red cell
transfusion can decrease transfusion requirements without increasing adverse … is to safely decrease the number of transfusions in PICUs and thereby
decrease transfusion-related events
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - ASK:
· How did the pilot CUSP team make a case for their project targeting adverse drug events?
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-tech-specs.pdf
December 14, 2011 - 7 g per deciliter for red-cell transfusion can decrease
transfusion requirements without increasing adverse
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - physician to observe overt and
many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting
a case and receiving feedback.42 The study reported a significant reduction in adverse … events and near-
misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency
department
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www.cahps.ahrq.gov/patient-safety/reports/advances/planning.html
July 01, 2022 - Studies
Blog
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About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … What recent or future events might help or hinder end user interest in your finding or product? … What recent/future events might help or hinder their willingness to work with you?