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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/873.html
July 01, 2023 - Studies
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Events … section
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Events … the Society of Thoracic Surgeons’ (STS) postoperative cardiac surgery guidelines is associated with adverse … events, according to an AHRQ-funded study in the Journal of Thoracic and Cardiovascular Surgery .
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www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/877.html
August 01, 2023 - Studies
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Events … section
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Events … Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-slides.pptx
April 01, 2022 - Safety Program for ICUs: Preventing CLABSI and CAUTI
Applying CUSP ׀ 10
10
Where To Find Defects8,9
Adverse … event reporting systems
Sentinel events
Claims data
Infection rates
Process audits
Staff safety assessments
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-acknowledgments.pdf
September 14, 2017 - advance the implementation of a transparent and just response to those who have been
injured due to an adverse … team at every phase of CANDOR development, including during tool synthesis, training,
and stakeholder events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0217-section-5-table-5.pdf
April 01, 2014 - following
for children with SCD experiencing pain:
Recognition and appropriate management of painful
events … Management of
vaso‐ occlusive pain events in sickle
cell disease. … management requires frequent
assessment to maintain pain control, make
adjustments due to tolerance or adverse
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-final508.pptx
April 10, 2018 - Adverse drug events
Unsafe medicine issues
Medicine adherence
Satisfaction
Reported use
Bring in medicines … We will use several measures to evaluate effectiveness:
How many adverse drug events occur pre- and
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www.qualitymeasures.ahrq.gov/research/findings/studies/index.html?page=485
January 01, 2024 - Studies
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Events … 1279)
2015
(1430)
2014
(662)
2013
(195)
Topics
Access to Care
(417)
Adverse … Drug Events (ADE)
(321)
Adverse Events
(737)
Alcohol Use
(61)
Ambulatory Care and Surgery
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www.qualitymeasures.ahrq.gov/patient-safety/news-events/psaw-2020/index.html
December 01, 2023 - Studies
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Events … Español
FAQs
Home
Patient Safety
Patient Safety News and Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … former Director of the Center for Quality Improvement and Patient Safety, highlights some of the planned events … https://www.ahrq.gov/patient-safety/news-events/psaw-2020/index.html
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www.qualitymeasures.ahrq.gov/hai/hai-carb-funding.html
November 01, 2021 - Studies
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Events … determine the clinical efficacy and effectiveness of preventive interventions including unintended adverse
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-071217.pptx
January 01, 2017 - TEAMSTEPPS 05.2
Slide ‹#›
2
Upcoming TeamSTEPPS Events
Master Training Courses
Registration for … TEAMSTEPPS 05.2
Slide ‹#›
A table shows the Most Frequently Identified Root Causes of Sentinel Events … Communication, and Leadership are in the top three positions for 2013, 2014, and 2015, totaling 79% of adverse … events.
13
TEAMSTEPPS 05.2
Slide ‹#›
A team of experts becomes an Expert Team.
14
TeamSTEPPS … Situation: She’s having a lot of ABD events that are now requiring stimulation.
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpra4.html
April 01, 2018 - Studies
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Events … important tool for assessing the risks associated with the occurrence of many different patient safety events … both individual contributors of risk, as well as unique combinations of risks that contribute to the adverse … toolkit of core fault trees for important safety problems such as medication errors, serious and sentinel events … that enable health care provider organizations better ways to examine other high-risk, low-base-rate events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - 70% ---- ----
New
2.0 item
Hospital management seems interested in
patient safety only after an adverse … (F3R)
Hospital management seems interested in
patient safety only after an adverse event
happens. … safety events have you reported? … (F3R)
Hospital management seems
interested in patient safety only
after an adverse event happens … safety events have you
reported?
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www.qualitymeasures.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/overview-slides.html
June 01, 2017 - Studies
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AHRQ News Now
Events … An analysis of risk factors and adverse events in ambulatory surgery .
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-quickstart-final508.pdf
April 04, 2018 - implementors and use them
as peer coaches.
6 Evaluate your progress
Evaluate effectiveness
� How many adverse … drug events occur pre-
and post-implementation?
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www.qualitymeasures.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-ref.html
September 01, 2015 - Studies
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AHRQ Views
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AHRQ News Now
Events … https://www.afsp.org/news-events/in-the-news/suicide-prevention-investment-needed-to-reverse-trend-of-increasing-suicide … Reducing the risk of adverse drug events in older adults.
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www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/etchegaray.html
August 01, 2017 - Studies
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AHRQ Views
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AHRQ News Now
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
Jason M. … Good disclosures can also involve soliciting patients’ perceptions of what caused the adverse event,
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
December 01, 2020 - Version 2019.01 of
the PSI software has 17 measures, in addition to 1 patient safety and adverse events … • Adverse events associated with surgical procedures.
• Hospital-acquired infections. … drug events 2004-2007 and 2009-2017
ADE - IV Heparin Adverse drug events 2004-2007 and 2009-2017
ADE … - Low Molecular Weight Heparin Adverse drug events 2004-2007 and 2009-2017
ADE - Warfarin Adverse drug … Adverse events after total knee arthroplasty: a
national Medicare study.
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.html
August 01, 2022 - Studies
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AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … advance the implementation of a transparent and just response to those who have been injured due to an adverse … team at every phase of CANDOR development, including during tool synthesis, training, and stakeholder events
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
September 01, 2023 - in the NPSD,
second only to Medication or Other
Substance events, making up approximately
10% … nationally, and cannot be used to calculate the actual prevalence of patient safety events. … among all events until it cannot find more common patterns that satisfy the specified frequency … harm is defined as harm to the patient after discovery of the incident and any attempts to
minimize adverse … Does error and adverse event reporting by physicians and nurses differ?
Jt. Comm. J. Qual.
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www.qualitymeasures.ahrq.gov/news/blog/ahrqviews/ahrq-digital-healthcare.html
February 01, 2024 - Studies
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Events … this section
News
Newsroom
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Events … It was an improbable endeavor to transform a field built on paper and adverse to change.