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  1. www.cpsi.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
  2. www.cpsi.ahrq.gov/patient-safety/about/areas.html
    February 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Learn about Patient Safety Patient Safety and Quality Areas Patient Safety News and Events … Team Training Falls Pressure Ulcers Diagnostic Safety Blood Clot Prevention and Treatment Adverse … Drug Events AHRQ Quality Indicators (QIs) Page last reviewed February
  3. www.cpsi.ahrq.gov/news/newsletters/e-newsletter/856.html
    March 01, 2023 - section News Newsroom Blog Newsletter AHRQ News Now Events … Articles featured this week include: Automated capture of intraoperative adverse events using artificial … Near-miss events detected using the emergency department trigger tool . … Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated … events in critically ill children.
  4. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c3_pdi_staffpresentation.pdf
    July 01, 2004 - pdi_resources.aspx • The PDIs are a set of 16 indicators that reflect quality of care inside hospitals and adverseevents 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 … Comparison between our hospital and peer hospitals – Our performance over time – Volume and cost of events
  5. www.cpsi.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
    January 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Assessment Form  (DOCX, 330 KB) Implementation Guide  (PDF, 402 KB) Learning From Antibiotic–Associated AdverseEvents Form (DOCX, 227 KB) Gap Analysis Tool  (DOCX, 382 KB) The Four Moments of Antibiotic Decision
  6. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
    December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … 1 2 3 4 5 SECTION D: Frequency of Events Reported In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an adverse event happens ....... … 1 2 3 4 5 SECTION G: Number of Events Reported In the past 12 months, how many event reports
  7. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
    April 01, 2011 - ------------------------------------------------------------------- 9 How to prevent adverse events … one study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge How does the IDEAL Discharge Planning strategy improve
  8. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
    April 01, 2011 - 9 How to prevent adverse events after discharge 11 How does the IDEAL Discharge Planning strategy improve … study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … How to prevent adverse events after discharge Many of the challenges described above can be attributed … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital.
  9. www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
    December 01, 2017 - mortality for pediatric surgical procedures Rates of potentially avoidable complications and adverse … for Selected Procedures) IQI 91 (Mortality for Selected Conditions) PSI 90 (Patient Safety and AdverseEvents Composite) PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … References Slide 48 Sample Best Practices Pressure ulcers represent an important patient adverse
  10. www.cpsi.ahrq.gov/news/newsletters/e-newsletter/900.html
    February 01, 2024 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Reducing Adverse Events Related to Anticoagulants . Implicit Bias Training . Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .
  11. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - multidisciplinary review is required to identify system processes that may result in failures in care, adverseevents, and mortality … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … department within 3 days of discharge ∗ Death associated with drug reaction ∗ Death associated with adverse … Summary data of sentinel events reviewed by The Joint Commission.
  12. www.cpsi.ahrq.gov/news/newsletters/e-newsletter/875.html
    August 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … section News Newsroom Blog Newsletter AHRQ News Now Events … Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis . … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality
  13. www.cpsi.ahrq.gov/talkingquality/translate/compare/choose/standard.html
    January 01, 2023 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … 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.”
  14. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
    May 01, 2017 - Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29–34.
  15. www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro-ig.pptx
    January 20, 2006 - Some of the current clinical outcomes of team training include the following: 50 percent reduction in adverse … percent decrease in the Severity Index, which measures the average severity of each delivery with an adverse … event (Mann, Marcus, & Sachs, 2006); Reduced rate of adverse drug events; and Improved medication reconciliation
  16. www.cpsi.ahrq.gov/research/findings/factsheets/primary/pbrn/index.html
    October 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … PBRN Web Events —PBRN researchers, directors, and staff participate in ongoing discussions dedicated … pandemic influenza event. 4 Field testing of a new ambulatory care electronic Medication Errors and Adverse … Drug Events Reporting System (MEADERS). 5 For More Information For more information on AHRQ's Primary … Field test results of a new ambulatory care Medication Errors and Adverse Drug Events Reporting System
  17. www.cpsi.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
    June 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … patient safety research and implementation projects, offers these 10 evidence-based tips to prevent adverseevents from occurring in your hospital. … used incorrectly, blood thinners can cause uncontrollable bleeding and are among the top causes of adverse … drug events.
  18. www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
    November 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now EventsAdverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual support … Staff members are concerned that we could have an adverse event due to breakdowns in team skills.   … prophylactic use of beta-blockers to prevent intra-operative myocardial ischemia]; decreased rates of adverseevents or near misses)   Who will be involved in the change?
  19. www.cpsi.ahrq.gov/news/events/conference/2011/jack/index.html
    October 01, 2014 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … More topics in this section News Newsroom Blog Newsletter Events … Fragmentation. 19% of patients have a post-discharge adverse events (AE). 20% of Medicare patients readmitted … https://www.ahrq.gov/news/events/conference/2011/jack/index.html   Back
  20. www.cpsi.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/references.html
    June 01, 2018 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … The effect of electronic prescribing on medication errors and adverse drug events: a systematic review … The incidence and severity of adverse events affecting patients after discharge from hospital.

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