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www.qualitymeasures.ahrq.gov/health-literacy/improve/pharmacy/medication-mgt.html
September 01, 2020 - Studies
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AHRQ News Now
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/patient-safety/about/areas.html
February 01, 2018 - Studies
Blog
AHRQ Views
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Events … Learn about Patient Safety
Patient Safety and Quality Areas
Patient Safety News and Events … Team Training
Falls
Pressure Ulcers
Diagnostic Safety
Blood Clot Prevention and Treatment
Adverse … Drug Events
AHRQ Quality Indicators (QIs)
Page last reviewed February
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
September 28, 2016 - • 1999 IOM: 98,000 people die each year from adverse events
• 2005: IHI launched first national campaign … reduction in HACs and that approximately $19.8 billion in health care costs
were saved from 2010 to 2014
Adverse … Drug
Events
Pressure
Ulcers
Catheter
Associated
Urinary
Tract
Infections
Surgical
Site … • Medical record reviews: diagnostic errors account for
6 to 17 percent of hospital adverse events
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/828.html
August 01, 2022 - Studies
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Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … and introduces Measure Dx , a new evidence-based tool that helps users identify diagnostic safety events … Drug-drug interactions are responsible for up to 14 percent of adverse drug reactions in hospitalized … Articles featured this week include:
Quality measures for patients at risk of adverse outcomes in the
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an
adverse event happens ....... … 1 2 3 4 5
SECTION G: Number of Events Reported
In the past 12 months, how many event reports
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an
adverse event happens ....... … 1 2 3 4 5
SECTION G: Number of Events Reported
In the past 12 months, how many event reports
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/856.html
March 01, 2023 - section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Articles featured this week include:
Automated capture of intraoperative adverse events using artificial … Near-miss events detected using the emergency department trigger tool . … Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated … events in critically ill children.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool1a.docx
January 01, 2004 - “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events resulting … afraid 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
3 … 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/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Studies
Blog
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Events … Assessment Form (DOCX, 330 KB)
Implementation Guide (PDF, 402 KB)
Learning From Antibiotic–Associated Adverse … Events Form (DOCX, 227 KB)
Gap Analysis Tool (DOCX, 382 KB)
The Four Moments of Antibiotic Decision
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - ------------------------------------------------------------------- 9
How to prevent adverse events … one study.1 Of these adverse events, three-quarters could
have been prevented or ameliorated. … At this time, no
consensus exists on the single best method to prevent adverse events after
discharge … The incidence and severity of adverse
events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge
How does the IDEAL Discharge Planning strategy improve
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - multidisciplinary review is required to identify system processes that may result
in failures in care, adverse … events, and mortality … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … Summary data of sentinel events reviewed by The Joint Commission.
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www.qualitymeasures.ahrq.gov/antibiotic-use/ambulatory-care/best-practices/skin-soft-tissue.html
September 01, 2022 - Studies
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AHRQ Views
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AHRQ News Now
Events … Identify empiric antibiotic regimens for cellulitis that minimize adverse events.
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www.qualitymeasures.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-apa.html
September 01, 2013 - Studies
Blog
AHRQ Views
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Events … Safety and Adverse Events
Publication: 13-0052-EF
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www.qualitymeasures.ahrq.gov/hai/universal-icu-decolonization/universal-icu-apa.html
September 01, 2013 - Studies
Blog
AHRQ Views
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Events … Safety and Adverse Events
Publication: 13-0052-EF
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - mortality for pediatric surgical procedures
Rates of potentially avoidable complications and adverse … for Selected Procedures)
IQI 91 (Mortality for Selected Conditions)
PSI 90 (Patient Safety and Adverse … Events Composite)
PDI 19 (Pediatric Patient Safety for Selected Indicators) are not in ICD-10 v6.0 … Consider inserting here the deidentified story of a patient who suffered the adverse event captured by … References
Slide 48
Sample Best Practices
Pressure ulcers represent an important patient adverse
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
May 01, 2007 - Corrective Action Reports
– Patient Safety Activity Documentation
– Policies; Corrective Action, Sentinel
Events … , Adverse Event Reporting
– Patient Safety Plan
– Code of Conduct, Employee Handbook,
Medical Staff
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro-ig.pptx
January 20, 2006 - Some of the current clinical outcomes of team training include the following:
50 percent reduction in adverse … percent decrease in the Severity Index, which measures the average severity of each delivery with an adverse … event (Mann, Marcus, & Sachs, 2006);
Reduced rate of adverse drug events; and
Improved medication reconciliation
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - ”
· “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … questions when something does not seem right
1
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3
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5
9
SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported?
a. … Hospital management seems interested in patient safety only after an adverse event happens
1
2
3
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www.qualitymeasures.ahrq.gov/talkingquality/translate/compare/choose/standard.html
January 01, 2023 - Studies
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Events … The Standard for “Never Events”
There is one kind of standard that is beginning to emerge in health … care: the standard of “never” or zero percent for certain adverse and preventable events. … These events are preventable and should never happen.”
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/900.html
February 01, 2024 - Studies
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Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Reducing Adverse Events Related to Anticoagulants .
Implicit Bias Training .
Deprescribing . … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events .