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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK1_T5-Draft_Policies_and_Procedures_for_the_Antimicrobial_Stewardship_Program_final.docx
October 01, 2016 - The adverse consequences of unnecessary antibiotic use include adverse drug reactions or interactions … this procedure can help reduce unnecessary prescribing and lead to fewer antibiotic failures and/or adverse … events.
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www.qualitymeasures.ahrq.gov/sops/bibliography/index.html?page=6
January 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patient safety culture and nurse-reported adverse events in outpatient hemodialysis units. … Are measurements of patient safety culture and adverse events valid and reliable? … The relationship between patient safety culture and adverse events: A questionnaire survey.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-1-implementation-guide.pdf
January 01, 2018 - o CR reduces mortality over 1-3 years after a cardiac event
o CR reduces re- hospitalization and adverse … events, such as subsequent MI
o CR can help patients with medication adherence, and management of multiple … chronic
conditions, diabetes, depression, mental stress and improves quality of life after an adverse … events
- CR reduces
morbidity and
mortality and
improves quality
of life
-CR reduces
avoidable … events – which are
metrics tracked and incentivized
by payers
o Review the information presented
-
www.qualitymeasures.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
January 01, 2004 - Because oral
anticoagulants are associated with preventable adverse events at
disproportionately high … events,4, 37 such as thrombotic events (under-treatment) or bleeding (over-
treatment). … events are common18 and warfarin is
involved in preventable adverse drug events at rates disproportionate … Incidence
and preventability of adverse drug events among older
persons in the ambulatory setting. … Adverse drug
events in ambulatory care. NEJM 2003 348(16):1556–
64.
19.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - events and close calls. … These organizations consistently minimize adverse events despite carrying out
intrinsically complex … Patient Safety Primer: Medication Errors and Adverse Drug Events
https://psnet.ahrq.gov/primers/primer … /23
A growing evidence base supports specific strategies to prevent adverse drug events (ADEs). … Patient Safety Primer: Medication Errors and Adverse Drug Events
9.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-rice.pdf
February 09, 2023 - Office of Patient Safety
PATIENT
SAFETY
Adverse Events
Root Cause
Analysis
PROJECT
MANAGEMENT … Management
Plans
Environment of
Care Committee
PERFORMANCE
IMPROVEMENT
Data Analysis
PI Teams & EPIC
Events
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www.qualitymeasures.ahrq.gov/news/newsroom/press-releases/smoking-cessation-disparities.html
December 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
Newsletter
Events … policymakers conduct cost-benefit analyses that accurately reflect the burden of healthcare costs and adverse … “Disparities in medical spending, as well as adverse health outcomes, are continuing to increase over
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/index.html
July 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and 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.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview.pptx
May 01, 2017 - An analysis of risk factors and adverse events in ambulatory surgery. … An analysis of risk factors and adverse events in ambulatory surgery. … Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
• Sentinel events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
November 01, 2019 - are different
Desire for autonomy
Difficulty perceiving the association between antibiotic use and adverse … events
Not paying attention or not interested
System challenges: inadequate communication, difficulty … are different2
Desire for autonomy
Difficulty perceiving the association between antibiotic use and adverse … events
Not paying attention or not interested
System challenges: inadequate communication, difficulty … 90% 88%
Adverse events
More adverse events with longer therapy!
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … to ask questions when something does not seem right
(1
(2
(3
(4
(5
SECTION D: Frequency of Events … Management in this facility seems interested in patient safety only after an adverse event happens … Shift changes are problematic for patients in this facility
(1
(2
(3
(4
(5
SECTION G: Number of Events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-slides.pptx
September 01, 2022 - sending urine cultures
Discuss empiric antibiotic options for UTIs that are effective and minimize adverse … events
Discuss recommended durations of antibiotic therapy for UTIs
2
ASB and UTI
AHRQ Safety Program … events 9,10
An increased risk of subsequent UTIs that may be increasingly difficult to treat due to … events
Review local susceptibility data, patient’s previous urine culture results and associated susceptibility … data, as well as antibiotic adverse event profile when selecting therapy
18
ASB and UTI
AHRQ Safety
-
www.qualitymeasures.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
April 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Cards and Outcome Measurements
Report
Protocol
Opioid Stewardship
Report
Protocol
Reducing Adverse … Events Related to Anticoagulants
Report
Protocol
Implicit Bias Training
Report
Protocol … Deprescribing
Report
Protocol
Computerized Clinical Decision Support To Prevent Medication Errors and Adverse … Drug Events
Report
Protocol
Failure To Rescue—Rapid Response Systems
Report
Protocol
Prevention
-
www.qualitymeasures.ahrq.gov/topics/transitions-care.html
Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse … events, drug-related errors, and other problems.
-
www.qualitymeasures.ahrq.gov/research/findings/evidence-based-reports/search.html?page=1
November 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Permanente Research Affiliates Report Status: Final
Efficacy of Dental Services for Reducing Adverse … Events in Those Receiving Chemotherapy for Cancer Date: July 2023
Report Type: Rapid Evidence Product … Scientific Resource Center Report Status: Final
Efficacy of Dental Services for Reducing Adverse … Events in Those Undergoing Insertion of Implantable Cardiovascular Devices Date: July 2023
Report
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/leadership-brief/ts-leadershipbrief.pptx
January 01, 2013 - 10 years and identified communication failure as the leading root cause of sentinel events. … Outcome Score, which describes the adverse event score per delivery
A 50% decrease in the Severity Index … , which measures the average severity of each delivery with an adverse event
Intensive Care Units2
After … years and identified communication failure as the leading root cause of sentinel events. … events and close calls.
19
What Does it Cost?
-
www.qualitymeasures.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
January 01, 2021 - billion), adverse drug events ($4.1 billion), and falls ($1.5 billion), while diagnostic errors have … By advancing our efforts to reduce these events, we can lessen these avoidable financial burdens and, … understanding where value is gained and lost, and incorporating strategies that are proven to reduce or prevent adverse … The 21 st Century Care Initiative presents a major opportunity to reduce preventable adverse medical … events and improve medication management through new, evidence-based, individualized care management
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
November 18, 2019 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or
adverse events … when something does not seem right .... 1 2 3 4 5
SECTION D: Frequency of Events … Management in this facility seems interested in patient safety only
after an adverse event happens … facility ........................... 1 2 3 4 5
SECTION G: Number of Events … Safety Grade
SECTION F: Your Facility
SECTION F: Your Facility (continued)
SECTION G: Number of Events
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/892.html
December 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Making Healthcare Safer IV will provide evidence on 11 additional safety topics, including reducing adverse … events related to anticoagulants, opioid stewardship and addressing fatigue and sleepiness of clinicians … Articles featured this week include:
Prescription opioid dose reductions and potential adverse events
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www.qualitymeasures.ahrq.gov/teamstepps/instructor/fundamentals/module10/slmeasure.html
March 01, 2014 - Frequency of events reported.
Supervisor/manager expectations and actions promoting safety. … The number of events the respondent reported in the last 12 months. … 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.