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www.qualitymeasures.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
December 01, 2023 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Readmissions
High rates of readmissions are a major patient safety problem associated with adverse … events such as prescribing errors and misdiagnoses of conditions in the hospital and ambulatory care
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www.qualitymeasures.ahrq.gov/antibiotic-use/long-term-care/safety/system-change.html
June 01, 2021 - Studies
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Events … Improve Antibiotic Safety – Facilitator Guide (DOCX, 2.3 MB)
Learning From Antibiotic-Associated Adverse … Events (DOCX, 226.7 KB)
Page last reviewed June 2021
Page originally
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/index.html?page=2
April 05, 2022 - Studies
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Events … Results
News
Newsroom
Blog
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Events … ascending
Top Story
April 5, 2022
Dental Opioid Prescriptions Associated With Adverse … Patient-Generated Health Data Into Electronic Health Records
February 8, 2022
Opioid Prescribing, Adverse … Change, Environmental Justice and AHRQ
October 5, 2021
Drug Label Changes Could Reduce Adverse
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www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-a.html
September 01, 2020 - Studies
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Events … Emphasize potential differences between patient safety events and adverse events and distinguish between … Clarify roles and responsibilities for all clinical and nonclinical staff pertaining to reporting safety events … misunderstandings, and lack of respect for cultural beliefs and traditions, may lead to patient safety events … Provide examples of how using nonqualified interpreters can have adverse effects on patient care.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
June 01, 2021 - assess pulse
• Oxygen
• Pulse oximeter
• Access to a phone to call 911
If a resident has an adverse … reaction after vaccination, nursing home staff should review the Vaccine
Adverse Event Reporting System … Name and title of person who administered the vaccine
• Vaccine route and site
• Dosage in mL
• Any adverse … events
igure 3 – Example
edical sharps container.
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
April 01, 2018 - It utilizes both quantitative and qualitative data to "map" the risks associated with adverse outcomes … interact with one another and either individually or collectively combine to contribute to the overall adverse … Is proactive, identifying the possible adverse events before they actually occur, thus enabling the decision … modeling of complex interactions and dependencies among the multiple risk points that may lead to the adverse … this approach is determining the probabilities associated with human breakdowns that contribute to adverse
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/videos/physicians.html
August 01, 2022 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events … This video demonstrates an example of emotional support provided for the physician caregiver after an adverse
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - Studies
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Events … Slide 28: Communicating Adverse Events
Say:
Communication following an adverse event can been especially … Slide 30: How To Communicate About An Adverse Event
Say:
It is important to remember that residents … and family members can experience a number of emotions when an adverse event occurs, so communication … about an adverse event should be compassionate and sensitive.
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www.qualitymeasures.ahrq.gov/news/newsroom/case-studies/201509.html
January 01, 2018 - AHRQ Social Media
AHRQ Stats
Impact Case Studies
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Events … the technicians' work, the E.D. pharmacist can interpret the patient's medication history to look for adverse … events, one of the many reasons patients come to the E.D. … Study Identifier:
2015-09
AHRQ Product(s):
Research
Topic(s):
Adverse … Drug Events (ADE),
Outcomes,
Patient Safety,
Provider: Pharmacist
Geographic
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/how-to-use.html
July 01, 2023 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … team members how to apply the Comprehensive Unit-based Safety Program (CUSP) to prevent obstetrical adverse … events.
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www.qualitymeasures.ahrq.gov/teamstepps/about-teamstepps/leadershipbriefing.html
April 01, 2017 - drug events (from 30 to 18 per 1,000 patient days). … 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 … events and close calls (VA Center for Patient Safety). … events and close calls.
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www.qualitymeasures.ahrq.gov/topics/antibiotics.html
Studies
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Events … Research Studies
Impact of reducing time-to-antibiotics on sepsis mortality, antibiotic use, and adverse … events.
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www.qualitymeasures.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
August 01, 2022 - Studies
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Events … the creation of PSOs and the development of Common Formats for uniform reporting of patient safety events … external experts who can assist providers in the collection, analysis, and aggregation of patient safety events … access to Common Formats (uniform definitions and reporting formats for collecting information about adverse … events).
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www.qualitymeasures.ahrq.gov/practiceimprovement/index.html
August 01, 2022 - Studies
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Events … Prevention
Tools to assist nursing homes that have electronic medical record systems to prevent adverse … events. … Communication and Optimal Resolution (CANDOR) Toolkit
Process for practitioners to use when unexpected events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - ............................................................................... 2
Descriptions of Events … • Patient safety concerns such as falls,
pressure injuries, and adverse medication
events were reported … Among the blood and blood product concerns (n = 10; 3.3%), there were three incidents involving an
adverse … In two instances, adverse reactions to medications used to treat COVID-19 were identified. … intervention in place
o Secondary patient morbidity
• Surgery or anesthesia
o Characteristics of surgical adverse
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www.qualitymeasures.ahrq.gov/health-literacy/improve/pharmacy/medication-mgt.html
September 01, 2020 - Studies
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Events … (MTM) is a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse … events, and improve medication adherence.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-slides.pptx
June 01, 2021 - antibiotics only when necessary, thereby protecting residents from unnecessary antibiotic exposure and adverse … events. … receiving a fluoroquinolone for 8 days without monitoring.
7
Developing a Program
7
Reviewing the Events … Cost of antibiotics
Use of guideline-concordant antibiotics
Clostridioides difficile infection rates
Adverse … events related to antibiotics
22
Developing a Program
22
Summary
23
Gather a motivated team
Brainstorm
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - · “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 … Hospital management seems interested in patient safety only after an adverse event happens
(1
(2 … Shift changes are problematic for patients in this hospital
(1
(2
(3
(4
(5
SECTION G: Number of Events
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www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/10-tips-for-hospitals.pdf
December 01, 2009 - patient
safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse … events from
occurring in your hospital. … used incorrectly,
blood thinners can cause
uncontrollable bleeding and are among the top causes of
adverse … drug events.
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www.qualitymeasures.ahrq.gov/teamstepps-program/resources/additional/sbar.html
July 01, 2023 - Studies
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Events … how this technique, one tool in the TeamSTEPPS training program, can improve communication, reduce adverse … events, and improve care quality.