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www.innovations.ahrq.gov/health-literacy/professional-training/lepguide/app-a.html
September 01, 2020 - Studies
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Events … Emphasize potential differences between patient safety events and adverse events and distinguish between … Clarify roles and responsibilities for all clinical and nonclinical staff pertaining to reporting safety events … misunderstandings, and lack of respect for cultural beliefs and traditions, may lead to patient safety events … Provide examples of how using nonqualified interpreters can have adverse effects on patient care.
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www.innovations.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - Studies
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Events … Slide 28: Communicating Adverse Events
Say:
Communication following an adverse event can been especially … 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.
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www.innovations.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
April 01, 2018 - Studies
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Events … Drug Events
96
420
---- Administration Errors
14
419
---- Dispensing Errors
11
448 … --- Ordering/Prescribing Errors
6
418
---- Transcription Errors
5
415
-- Side Effects/Adverse … 621
---- Governmental Reporting
1
622
---- Institutional Reporting
2
690
---- Never Events … Robotic-Assisted Surgery
0
665
---- Computer-Assisted Radiotherapy
0
661
-- Computerized Adverse
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www.innovations.ahrq.gov/news/newsroom/case-studies/201509.html
January 01, 2018 - AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
Newsletter
Events … the technicians' work, the E.D. pharmacist can interpret the patient's medication history to look for adverse … events, one of the many reasons patients come to the E.D. … Study Identifier:
2015-09
AHRQ Product(s):
Research
Topic(s):
Adverse … Drug Events (ADE),
Outcomes,
Patient Safety,
Provider: Pharmacist
Geographic
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www.innovations.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/how-to-use.html
July 01, 2023 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … team members how to apply the Comprehensive Unit-based Safety Program (CUSP) to prevent obstetrical adverse … events.
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www.innovations.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
August 01, 2022 - Studies
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Events … the creation of PSOs and the development of Common Formats for uniform reporting of patient safety events … external experts who can assist providers in the collection, analysis, and aggregation of patient safety events … access to Common Formats (uniform definitions and reporting formats for collecting information about adverse … events).
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www.innovations.ahrq.gov/practiceimprovement/index.html
August 01, 2022 - Studies
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Events … Prevention
Tools to assist nursing homes that have electronic medical record systems to prevent adverse … events. … Communication and Optimal Resolution (CANDOR) Toolkit
Process for practitioners to use when unexpected events
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … to ask questions when something does not seem right
(1
(2
(3
(4
(5
SECTION D: Frequency of Events … Hospital management seems interested in patient safety only after an adverse event happens
(1
(2 … Shift changes are problematic for patients in this hospital
(1
(2
(3
(4
(5
SECTION G: Number of Events
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www.innovations.ahrq.gov/news/newsletters/e-newsletter/872.html
July 01, 2023 - process can enrich clinicians’ understanding of patient and family experience and reduce harms following adverse … diagnostic events. … It describes the most effective ways of eliciting fulsome accounts about diagnosis-related events and … emergency departments to provide nonemergency care to residents, potentially placing residents at risk of adverse … events and generating wasteful Medicare spending.
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www.innovations.ahrq.gov/patient-safety/about/areas.html
February 01, 2018 - Studies
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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.innovations.ahrq.gov/news/newsletters/e-newsletter/856.html
March 01, 2023 - section
News
Newsroom
Blog
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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.innovations.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.innovations.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.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 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.innovations.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.innovations.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.innovations.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.innovations.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
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Events … section
News
Newsroom
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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.innovations.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.innovations.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - Studies
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Events … section
News
Newsroom
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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