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www.innovations.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
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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.innovations.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.innovations.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.innovations.ahrq.gov/research/findings/factsheets/primary/pbrn/index.html
October 01, 2018 - Studies
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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.innovations.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Studies
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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.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
May 01, 2007 - Corrective Action Reports
– Patient Safety Activity Documentation
– Policies; Corrective Action, Sentinel
Events … , Adverse Event Reporting
– Patient Safety Plan
– Code of Conduct, Employee Handbook,
Medical Staff
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www.innovations.ahrq.gov/news/newsletters/e-newsletter/890.html
November 01, 2023 - Studies
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Events … section
News
Newsroom
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Events … antibiotics within 48 hours of presentation and in 13 percent of hospitalizations patients experienced an adverse … time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse … events were rare.
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www.innovations.ahrq.gov/news/newsletters/e-newsletter/907.html
April 01, 2024 - Studies
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Events … section
News
Newsroom
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AHRQ News Now
Events … of team strategies and tools to improve performance and approaches to team-based error disclosure on adverse … events. … Articles featured this week include:
Transfusion-related errors and associated adverse reactions and
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www.innovations.ahrq.gov/news/newsletters/e-newsletter/884.html
October 01, 2023 - Studies
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Events … section
News
Newsroom
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Events … Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality … Risk factors for opioid-related adverse drug events among older adults after hospitalization for major
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol.pdf
February 02, 2018 - These physiologic aberrations may result in
several adverse outcomes that include, but are not limited … events? … events
• Timing
o At least 1 month of treatment
• Setting
o Home
o Assisted living residence … (KQ 5)
Adverse
Events
Table 1. … events
Timing At least 1 month of treatment in
home settings
None
Settings Therapy (BPAP, CPAP
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - ”
• “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5 9
5
SECTION D: Reporting Patient Safety Events
Think about your unit/work … In the past 12 months, how many patient safety events have you reported?
a. … Hospital management seems interested in
patient safety only after an adverse event
happens .......
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www.innovations.ahrq.gov/news/newsletters/e-newsletter/874.html
August 01, 2023 - Studies
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Events … section
News
Newsroom
Blog
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AHRQ News Now
Events … available to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures. … Articles featured this week include:
Anticoagulation-associated adverse drug events in hospitalized
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www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … communicators who participate in conversations with patients, families, and caregivers following an adverse … demonstrate all of the skills and competencies should be involved in delivering communication about adverse … events to patients, families, and caregivers.
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www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … management
Disruptive behavior and/or code of conduct
Investigation of occurrences (i.e., sentinel events … ___
Bylaws for medical staff and/or hospital
Peer review process
Oversight/management of adverse … or "harm" events
___
___
Organizational safety and/or quality plan
FMEAs or other
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www.innovations.ahrq.gov/teamstepps/officebasedcare/impworkbook.html
December 01, 2015 - Studies
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Events … □ Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual … Near-miss(es) due to breakdowns in team skills
□ Staff members are concerned that we could have an adverse … patient satisfaction; improved performance on a relevant health care quality measure; decreased rates of adverse … events or near-misses)
Who will be involved in the change?
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www.innovations.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Studies
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Events … hospitals and nursing homes (including skilled nursing facilities) to collect data for all types of adverse … events, near misses, and unsafe conditions. … Research suggests that adverse events affect patients with limited English proficiency more frequently … If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications
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www.innovations.ahrq.gov/patient-safety/reports/candor-demo-program/candor/demo-program/index.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … These projects sought to improve patient safety by measuring safety problems, characterizing adverse … events, and conducting clinical safety interventions.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
January 01, 2010 - engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse … of these could have been prevented
or ameliorated.1 Common post-discharge complications
include adverse … drug events, hospital-acquired infections,
and procedural complications.1 Many of these
complications … The
incidence and severity of adverse events affecting
patients after discharge from the hospital.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - for engaging patients and families in discharge planning
Nearly 20 percent of patients experience an adverse … three-quarters of these could have been prevented
or ameliorated.1 Common post-discharge complications include adverse … drug events, hospital-acquired infections, and procedural complications.1 Many of these complications … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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www.innovations.ahrq.gov/topics/index.html?page=1
January 01, 2012 - Studies
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Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.