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November 01, 2022 - Studies
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Events … The preventable harms for these medication errors include adverse drug events (ADEs), unscheduled hospital
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February 01, 2020 - Studies
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Events … Trauma (e.g., adverse childhood experiences, domestic violence, elder abuse).
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April 01, 2023 - Studies
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Events … Understanding patient and clinician reported nonroutine events in ambulatory surgery. … Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex
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March 01, 2023 - Studies
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Events … non-Hispanic Black adult hospital patients who received a hypoglycemic agent experienced a related adverse … In 2019, the rate of severe maternal morbidity events was 12.3, 8.7 and 8.2 per every 1,000 delivery
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - for Ambulatory Surgery
6
Studies show that communication failures are the cause of 80 percent of adverse … for the entire team
Cards were placed in every operating room
Reduced wrong-site surgeries and other adverse … events
Increased staff morale
Reduced nursing turnover
4Shepard S. … Ensures all team members are on the same page
Confirms critical information
Provides a place to discuss adverse … or potentially adverse events that occurred
Facilitates discussion of how to stop problems from reoccurring
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June 01, 2021 - Studies
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Events … section
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Events … Promoting the psychological well-being of healthcare providers facing the burden of adverse events: a
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
August 22, 2023 - The board’s tracking of adverse events and delineated types of errors (including near misses) -
focus … ensure they have/are part of QAPI efforts where
appropriate and understand how to identify and report events … complaints in
cardiology and cardiac
surgery
• Patient mortality triple
the norm and rise in
adverse … events and
claims (often lagging
indicators)
• Patient complaints
• Culture of Non-
transparency … • Could a department hide
embarrassing events from
management and the board?
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www.innovations.ahrq.gov/evidencenow/projects/alcohol/index.html
November 01, 2023 - Studies
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Events … It is associated with adverse effects on physical and mental health.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pdf
May 22, 2013 - • Nearly 20 percent of patients experience an adverse event
within a month of discharge, of which ¾ … could be prevented
• Common complications post-discharge are adverse drug
events, hospital-acquired
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
March 01, 2016 - The measure will provide a mechanism to help assess the
appropriateness of deliveries and prevent adverse … The evidence behind the inappropriate use of cesarean delivery and its link to increased risk of
adverse … We set the minimum number required as 10
events. … events. … evaluated at the minimum number of quality reporting events.
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www.innovations.ahrq.gov/data/infographics/index.html
March 01, 2024 - Studies
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Events … Family Premiums for Employer-Sponsored Health Insurance
Growing Pain of Spinal Stenosis
Adverse … Drug Events Occurring in U.S.
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March 01, 2024 - Studies
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Events … treatment options and have the strongest evidence base for improving ADHD symptoms but are associated with adverse … events, such as appetite suppression.
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www.innovations.ahrq.gov/teamstepps/instructor/fundamentals/module10/igmeasure.html
March 01, 2014 - Studies
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Events … PSIs are a set of measures that provide information about potential in- hospital complications and adverse … events (outcomes) following surgeries, procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse events that might require further study … Such events can be mitigated with the implementation of TeamSTEPPS tools and strategies.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module10/igmeasure.pdf
January 01, 2004 - PSIs
are a set of measures that provide information about potential in-
hospital complications and adverse … events (outcomes) following
surgeries, procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse
events that might require further … also include
indicators for complications occurring in-hospital that may
represent patient safety events … Such events can be mitigated
with the implementation of TeamSTEPPS tools and strategies.
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www.innovations.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
February 01, 2018 - Studies
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Events … Careers
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Events … However, some medication-based treatments are likely to cause short-term adverse effects. … https://www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
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www.innovations.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - Studies
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Events … this section
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Events … Clearly, the COVID-19 pandemic has further illuminated the scale and adverse impacts of this problem,
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
December 01, 2020 - Importance of Patient Safety
Mortality
Prevalence
Cost
Findings on Patient Safety
Improving Trend: Adverse … Drug Events With Heparin and Factor Xa
Improving Trend: Inpatient Adverse Drug Events With Anticoagulants
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November 01, 2023 - Studies
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Events … Adverse drug event prevention and detection in older emergency department patients .
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www.innovations.ahrq.gov/coronavirus/long-covid.html
March 01, 2024 - Studies
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Events … pattern and progression or worsening over time, with the possibility of severe and life-threatening events … to improve the care of people living with multiple chronic conditions who are at increased risk for adverse
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www.innovations.ahrq.gov/teamstepps/instructor/essentials/implguide.html
November 01, 2018 - Studies
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Events … supporting the need for a TeamSTEPPS Intervention could originate from a variety of sources, including adverse … Available organizational data, (e.g., adverse event and near miss reports, AHRQ Patient Safety Culture … so that facilities may also use the Guide to develop TeamSTEPPS Action Plans in response to sentinel events