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www.innovations.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/slides.html
September 01, 2017 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem.
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www.innovations.ahrq.gov/questions/resources/20-tips.html
November 01, 2020 - Studies
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Events … Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
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www.innovations.ahrq.gov/sdoh/data-analytics.html
July 01, 2022 - Studies
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Events … security, transportation, financial strain, general well-being, social connectedness, physical safety, and adverse
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www.innovations.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
May 01, 2017 - Studies
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Events … Studies have found that communication failures are the cause of up to 80 percent of operating room adverse … events. … Use of the briefing card led to a drop in wrong-site surgeries and other adverse events. … Voicing Concerns in the Surgical Environment Is Important
Say:
Studies show that many times when adverse
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www.innovations.ahrq.gov/data/apcd/backgroundrpt/discuss.html
April 01, 2017 - Studies
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Events … ordering of laboratory testing or imaging, outpatient visits for chronic disease, and ambulatory care for adverse … events following ambulatory surgery or hospitalization. 8 , 9
Pediatric care.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
January 01, 2023 - page provides tips to encourage staff members to report conditions that could
lead to near-misses or adverse … events.
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www.innovations.ahrq.gov/patient-safety/reports/liability/pichert.html
August 01, 2017 - Studies
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Events … System in the Sanford Health System
Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Transitional Care Medication Safety: Stakeholders' Perspectives
Medication Discrepancies and Potential Adverse … Drug Events During Transfer of Care from Hospital to Home
James W. … Patient complaints and adverse surgical outcomes. Am J Med Qual 2016; 31(5):415–22.
xxix.
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www.innovations.ahrq.gov/ncepcr/tools/cultural-competence/oralling.html
July 01, 2019 - Studies
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Events … Further, M+COs may not recognize the serious adverse health impact that inadequate linguistic services
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www.innovations.ahrq.gov/health-literacy/professional-training/lepguide/app-e.html
September 01, 2020 - Studies
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Events … Update presents 34 practices that have been demonstrated to be effective in reducing the occurrence of adverse … healthcare events.
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem. … Memo on never events, July 7, 2008.
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www.innovations.ahrq.gov/news/newsroom/ahrq-stats.html
November 01, 2023 - (Source: Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem Inflammatory … Measures showing the most improvement included reduced adverse events among hospital patients receiving … (Source: Healthcare Cost and Utilization Project Statistical Brief #237: Patient Safety and Adverse … Events, 2011 and 2014 .) … Events, 2011 and 2014 .)
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
July 01, 2018 - provide an overall
grade on patient safety for their work area/unit and to indicate the number of events … “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … Hospital management seems interested in patient safety only after an
adverse event happens ......... … Hospital management seems interested in patient safety only after an adverse event
happens. … Frequency of Events Reported
(Never, Rarely, Sometimes, Most of the time, Always)
D1.
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www.innovations.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
March 01, 2017 - Studies
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Events … In addition, the toolkit can enable teams to address root causes of adverse events more effectively. … It investigates events or safety concerns, and determines an appropriate course of action with the employees
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www.innovations.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
December 01, 2017 - Studies
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Events … Percent know correct action for hypoglycemic symptoms
38
53.9
72.6
Slide 8
All Sentinel Events … limited health literacy:
Poor compliance with medical management
Increased risk of:
Poor outcomes/adverse … events
Infections/prolonged hospital stays
Patient/family anxiety
Slide 33
Summary: Health
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www.innovations.ahrq.gov/ncepcr/tools/cultural-competence/planclas.html
July 01, 2019 - Studies
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Events … Further, M+COs may not recognize the serious adverse health impact that lower levels of cultural competence
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4h_pdi10-sepsis-bestpractices.pdf
May 17, 2016 - Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4v_combo_pdi10-sepsis-bestpractices.pdf
May 17, 2016 - Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
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www.innovations.ahrq.gov/pqmp/implementation-qi/toolkits.html
August 01, 2021 - Studies
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Events
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-fullreport.pdf
February 14, 2018 - of psychiatric disorders in children,
these medications are associated with a number of potentially adverse … Fiscal Burden
Although there is little research available on the fiscal burden associated with adverse … aspect of proper medication
management in this population, as these medications are associated with adverse … Antipsychotics are associated with potentially
adverse metabolic impacts that include weight gain, diabetes … Health-care costs of pediatric clients developing adverse events during
treatment with antipsychotics
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www.innovations.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