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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
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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
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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.
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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 adverse … 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 … Comparison between our hospital and peer
hospitals
– Our performance over time
– Volume and cost of events
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www.cpsi.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events … Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse … Events Form (DOCX, 227 KB)
Gap Analysis Tool (DOCX, 382 KB)
The Four Moments of Antibiotic Decision
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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
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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
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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.
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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 Adverse … Events 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
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
Blog
AHRQ Views
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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 .
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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, adverse … events, 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.
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www.cpsi.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Studies
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AHRQ Views
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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
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www.cpsi.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
Blog
AHRQ Views
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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.”
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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.
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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
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www.cpsi.ahrq.gov/research/findings/factsheets/primary/pbrn/index.html
October 01, 2018 - Studies
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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
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www.cpsi.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
June 01, 2018 - Studies
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AHRQ News Now
Events … patient safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse … events from occurring in your hospital. … used incorrectly, blood thinners can cause uncontrollable bleeding and are among the top causes of adverse … drug events.
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www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Studies
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AHRQ Views
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AHRQ News Now
Events … Adverse 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 adverse … events or near misses)
Who will be involved in the change?
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www.cpsi.ahrq.gov/news/events/conference/2011/jack/index.html
October 01, 2014 - Studies
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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
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www.cpsi.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/references.html
June 01, 2018 - Studies
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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.