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www.qualitymeasures.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - care, where the complexity of the system and the fragility of the patients creates a greater risk for adverse … events. … a 2-year AHRQ grant in 2005 to evaluate an emergency medicine clinical pharmacist program to avoid adverse … drug events in emergency department (ED) patients. … Fairbanks evaluated over 10,000 ED cases for adverse events, and interviewed ED physicians and nurses
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - Learning From Antibiotic-Associated Adverse Events Form
Changing the System
12
What Happened? … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.
… Completion Guide for the Four Moments of Antibiotic Decision Making Form
Learning From Antibiotic-Associated Adverse … Events
Changing the System
19
Disclaimer
The findings and recommendations in this presentation
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www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - 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
Carole Hemmelgarn
Three … Some of the key elements of CRPs are reporting and responding to adverse events, continuous communication … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals.
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www.qualitymeasures.ahrq.gov/programs/index.html?page=2
April 28, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … To reduce HACs and other adverse events in hospitals, frontline clinicians and others use many of the … uses electronic medical records to develop weekly reports that identify residents at risk of common adverse … events in nursing homes to help clinical staff intervene early.
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
July 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse … events resulting from poor communication and system failures. … Simulations—that an L&D unit can use to teach team members how to apply CUSP to prevent obstetrical adverse … events.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro.pptx
January 01, 2010 - critical role in providing quality health care
Clinical outcomes include:
50% reduction in the Weighted Adverse … Outcome Score, which describes the adverse event score per delivery
50% decrease in the Severity Index … , which measures the average severity of each delivery with an adverse event (Mann, et al., 2006)
Reduced … rate of adverse drug events
Improved medication reconciliation at patient admission (Haig, et al., 2006
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www.qualitymeasures.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Older adults have a high prevalence of chronic pain and are especially vulnerable to adverse events from … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
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www.qualitymeasures.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
June 01, 2018 - In the landmark Harvard Medical Practice Study of hospitals in New York State, adverse events, where … Of these adverse events, nearly 14 resulted in death. … Investigators attributed negligence as the cause of 27.6 percent of the adverse events and 51.3 percent … In fact, the authors of the study estimated that preventable adverse drug events would cost an additional … drug events would be $2 billion annually.
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/848.html
January 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … published in the journal Cancer found that 10 percent of children with leukemia or lymphoma experienced adverse … drug events due to outpatient medication errors. … systematic review, from AHRQ’s Effective Health Care Program, also found PBI had significantly fewer acute adverse … events than WBI, though there was no apparent difference in late adverse events.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-6b-table-b1.pdf
February 02, 2018 - Table 7.B
Table VI.B.1
Identifying a record with one or more adverse … events Specificity Sensitivity
Internal primary reviewers vs External expert primary reviewers 0.91
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www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/acknowledgements.html
August 01, 2017 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and 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
Advances in Patient Safety
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www.qualitymeasures.ahrq.gov/research/findings/evidence-based-reports/search.html
April 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Affiliation: RTI International—University of North Carolina at Chapel Hill Report Status: Final
Adverse … Status: Final
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … International—University of North Carolina at Chapel Hill Report Status: Final
Reducing Adverse … Drug Events Related to Anticoagulant Use in Adults Date: January 2024
Report Type: Rapid Evidence
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www.qualitymeasures.ahrq.gov/pqmp/measures/global-assessment.html
August 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Pediatric Patient Safety PQMP COE: CEPQM Associated NQF # and Name: 3136, GAPPS: Rate of Preventable Adverse … Events Per 1,000 Patient-Days Among Pediatric Inpatients
Products: Full Report (PDF, 289.7 KB)
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - ensure that these tiers of support are provided to caregivers after they have in been involved in an adverse … responsible for item or Action Plan
Reporting Culture
Are policies in place to support reporting adverse … clinical events? … Does your facility review patient safety events openly and share lessons learned? … YES NO
Adverse Event Investigation Process
Is an adverse event policy in place?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-may2015.pptx
January 01, 2015 - Safety in the US: Ongoing Problems
Institute of Medicine, 1999
44,000-98,000 deaths per year due to adverse … events
Office of the Inspector General, 2010
180,000 deaths per year due to adverse events
North Carolina … 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
I-PASS
Slide ‹#›
Results: Medical Error and Preventable Adverse … JAMA 2013; 310: 2262-2270
Pre-RHB Post-RHB p-value
Medical Errors 33.8 18.3 <0.001
Preventable Adverse … implementation associated with:
Primary outcome
A significant reduction in overall error rates and preventable adverse
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
October 01, 2015 - by the Agency for Healthcare Research and Quality (AHRQ) to provide
information on safety-related adverse … events occurring in hospitals following operations,
procedures, and childbirth. … The provider-level indicators can be used to help hospitals identify
adverse events worthy of further … study and to assess the incidence of such events for comparative
purposes. … Some of these indicators also have area-level analogs designed to detect patient safety
events on a
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module10/slmeasure.pptx
February 03, 2006 - Items
Unit-level safety areas
Hospitalwide safety areas
Overall perceptions of safety
Frequency of events … Overall items
The patient safety “grade” respondents would assign their work area/unit
The number of events … Safety Indicators (PSIs)
Level IV Results
Provide information on potential in-hospital complications and adverse … events
Can help identify potential adverse events that might need further study
Include indicators … for in-hospital complications that may represent patient safety events
Quality Indicators
TEAMSTEPPS
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/ltc-implementation-guide.pdf
June 01, 2021 - LabID events are defined on this
CDC site: https://www.cdc.gov/nhsn/faqs/faq-mdro-cdi.html. … on units for frontline
providers to complete when they identify a potential antibiotic-associated adverse … events as well as
first- and second-order problem-solving approaches. … with these discussions between ASPs and frontline staff:
− The Learning From Antibiotic-Associated Adverse … to guide strategies to
prevent future antibiotic-associated adverse events.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/common-cold-guide.docx
September 01, 2022 - Harm associated with antibiotics includes adverse drug events, microbiome disruption, and antibiotic … Adverse drug events from antibiotics are very common. … Patients are four times as likely to require an emergency department visit for an adverse event related … events from the medications should be taken into consideration before recommending them to individual … In fact, they could lead to an adverse event, like diarrhea, that could make it harder to participate
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/data/infographics/breast-cancer-radiotherapy.pdf
February 21, 2023 - Cancer-Free
Survival
Outcomes Similar at 5 and 10 Years
Whole Breast
Irradiation (WBI) Acute
Adverse … Events Were
Significantly
Fewer With
PBI
Compared
With WBI
Partial Breast
Irradiation (PBI)