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www.cpsi.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
June 01, 2018 - Studies
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Events … Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility
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www.cpsi.ahrq.gov/research/findings/final-reports/ptflow/section5.html
July 01, 2018 - Studies
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Events
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www.cpsi.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.cpsi.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.cpsi.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.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Have there been any notable adverse events that were pressure-ulcer related?
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www.cpsi.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.cpsi.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.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/translating/action3/ACTION%20-III-2019-Project-Summaries.pdf
January 01, 2019 - Each year, approximately 965,000 individuals will have a coronary event, and more than 30
percent of events … It is associated with a wide range of adverse consequences related to
physical and mental health (e.g … The risks of adverse medication events also differ for older adults, including falls, respiratory
depression … events and opioid use,
misuse, and OUD in older adults in primary care;
o Their experiences caring … drug events: a systematic review.
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www.cpsi.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.cpsi.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
November 01, 2020 - as well as from adverse drug reactions. … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical … Providers treating adverse events in outpatient settings may include office-based physicians, hospital … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable … sense of the burden these events place on the population.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bonner.pdf
January 01, 2004 - to a clinician
who can assess the level of urgency of the situation is part of a complex chain of
events … Only one reportable adverse event
ensued.11 No revisions of the policy were necessary. … Risks to patient
privacy in adverse event reporting for HSR&D
studies.
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www.cpsi.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
-
www.cpsi.ahrq.gov/patient-safety/reports/advances/vol3.html
July 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
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www.cpsi.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.cpsi.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part2-infmat.html
June 01, 2018 - Studies
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Events … out-of-wedlock birth, or a high-parity birth, all of which are more likely to be unintended and associated with adverse
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www.cpsi.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Studies
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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.cpsi.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
April 01, 2017 - Studies
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Events … safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … The 50-item T-TPQ was tested and refined during three critical events: cognitive interviews, small group
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www.cpsi.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.cpsi.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