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www.innovations.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module6/ts2-0ltc_module6_support_evbase.pdf
January 01, 2013 - 14 reduce hospital costs by 19 percent,15
increase staff understanding of goals,16 reduce patient adverse … events,15 ,17 reduce
mortality,18 and reduce malpractice suits by 50 percent.15
Research has demonstrated
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www.innovations.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/overview.html
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www.innovations.ahrq.gov/funding/grantee-profiles/grtprofile-trautner.html
October 01, 2023 - Studies
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Events … Taking prescription antibiotics without a prescription increases the risk of antibiotic resistance, adverse
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
December 01, 2023 - Standard forms for the data collection and model procedures for the uniform
registration of the events … , such as medication
prescriptions and laboratory test results that are relevant to patient safety events … Measures and modules included in calculation of adverse event rates
Measure Module
One or more adverse … outcomes Birth - Maternal
Adverse event associated with hypoglycemic agent Medication
Adverse event … events Pressure Ulcer
Venous thromboembolism/pulmonary embolism
(VTE/PE) not related to procedure
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www.innovations.ahrq.gov/pcor/library-of-resources/index.html
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Events … database , which contains information on study participants and a summary of study outcomes, including adverse … events.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - 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. … Future events are simply described. … Conventional Responses can include…
■ Describe Mary’s current condition and the events that led up to
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www.innovations.ahrq.gov/teamstepps/instructor/reference/teamattitudesmanual.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 ). … Adverse events may be reduced by maintaining an information exchange with patients and their families
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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-facnotes.docx
May 01, 2017 - Studies have found that communication failures are the cause of up to 80 percent of operating room adverse … events. … Furthermore, lack of communication has resulted in serious patient safety events such as teams performing … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Slide 43
SAY:
Studies show that many times when adverse events occur in the surgical environment,
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Regenstein_54.pdf
May 08, 2008 - one study, language barriers are associated with
1
2
an increased risk for serious medical events … during pediatric hospitalizations.12 For patients with
LEP, adverse events occurring during hospitalization … Are language
barriers associated with serious medical events in
hospitalized pediatric patients? … Language
proficiency and adverse events in U.S. hospitals: A
pilot study.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/reference/teamattitudesmanual.pdf
October 01, 2008 - safety, leadership, interpersonal interactions, attitudes toward stress, and
knowledge of how to report adverse … events (Sexton, et al., 2006). … Adverse events may be reduced by maintaining an information exchange with patients and their families
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-asa-measure.pptx
April 01, 2016 - Measure Exceptions
Adverse effect, allergy, or intolerance to Aspirin and Plavix (Clopidogrel). … Ischemic Vascular Disease
Secondary prevention is where the evidence is the best
Reduces risk of vascular events
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf
February 23, 2012 - events during childbirth. … The Work Group also aimed to develop an
outcome measure assessing adverse events during birth. … problems with this measure, such as risk adjustment, attribution, and the very low
incidences of these events … events at this time. … Adverse effects of prenatal alcohol exposure can range from
subtle developmental problems, or fetal
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-mc4-fullreport.pdf
July 01, 2016 - Maternal obesity is associated with adverse pregnancy outcomes, including increased risk for
gestational … per physician and two, at the
average number of quality reporting events per physician. … We set the minimum number required
as 10 events. … bias introduced by the inclusion of physicians without a significant
numbers of events. … The CPP states this important measure of addressing obesity can help
to reduce adverse maternal and
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www.innovations.ahrq.gov/news/newsroom/case-studies/index.html?page=7
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Events … User Liaison Program (ULP)
(4)
WebM&M
(5)
Topics
Access to Care
(14)
Adverse … Drug Events (ADE)
(5)
Asthma
(2)
Behavioral Health
(16)
Blood Clots
(15)
Blood Thinners
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - abdominal surgeries, and is
associated with significant risk of mortality between 14% and 50%.1 Other adverse … events
include prolonged length of stay, subsequent surgeries and incisional herniation.2,3
• Proper
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - foreign objects avoidable.1
• Retained foreign objects represent a serious and significant patient adverse … Chasing zero events of harm: an urgent call to expand safety culture work and
customer engagement.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module1/ts2-0ltc_module1_ig_intro.pdf
January 01, 2007 - drug events;
– Prevent central line infections;
– Prevent surgical site infections; and … events.
2016
• CMS released new long-term care regulations, which included the
mandate for all nursing … clinical decisionmaking by using the electronic medical record to track patients at risk for costly adverse … events … events
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
February 23, 2012 - events during childbirth. … The Work Group also aimed to develop an
outcome measure assessing adverse events during birth. … problems with this measure, such as risk adjustment, attribution, and the very low
incidences of these events … events at this time. … Adverse effects of prenatal alcohol exposure can range from
subtle developmental problems, or fetal
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternitycare.pdf
February 23, 2012 - events during childbirth. … The Work Group also aimed to develop an
outcome measure assessing adverse events during birth. … problems with this measure, such as risk adjustment, attribution, and the very low
incidences of these events … events at this time. … Adverse effects of prenatal alcohol exposure can range from
subtle developmental problems, or fetal
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www.innovations.ahrq.gov/priority-populations/about/index.html
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