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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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February 01, 2020 - Studies
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Events … Trauma (e.g., adverse childhood experiences, domestic violence, elder abuse).
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www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/867.html
June 01, 2023 - Studies
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Events … The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study .
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June 01, 2021 - Studies
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Events … Promoting the psychological well-being of healthcare providers facing the burden of adverse events: a
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/action-alliance/CMS-Aug-23-board-session.pdf
August 22, 2023 - The board’s tracking of adverse events and delineated types of errors (including near misses) -
focus … ensure they have/are part of QAPI efforts where
appropriate and understand how to identify and report events … complaints in
cardiology and cardiac
surgery
• Patient mortality triple
the norm and rise in
adverse … events and
claims (often lagging
indicators)
• Patient complaints
• Culture of Non-
transparency … • Could a department hide
embarrassing events from
management and the board?
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www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/861.html
April 01, 2023 - Studies
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Events … Understanding patient and clinician reported nonroutine events in ambulatory surgery. … Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex
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March 01, 2023 - Studies
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Events … non-Hispanic Black adult hospital patients who received a hypoglycemic agent experienced a related adverse … In 2019, the rate of severe maternal morbidity events was 12.3, 8.7 and 8.2 per every 1,000 delivery
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - Health Policy,
Saint Vincent College
Presentation Available
https://www.cahps.ahrq.gov/News-and-Events … access to those results or lower quality
of care with potential safety issues, such as we see with adverse … https://www.cahps.ahrq.gov/News-and-Events/Podcasts.aspx
Teamwork in Quality Improvement
February
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November 01, 2023 - Studies
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Events … It is associated with adverse effects on physical and mental health.
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www.talkingquality.ahrq.gov/patient-safety/news-events/psaw-2019/index.html
July 01, 2022 - Studies
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Patient Safety News and Events … https://www.ahrq.gov/patient-safety/news-events/psaw-2019/index.html
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www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/906.html
March 01, 2024 - Studies
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Events … treatment options and have the strongest evidence base for improving ADHD symptoms but are associated with adverse … events, such as appetite suppression.
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www.talkingquality.ahrq.gov/data/infographics/index.html
March 01, 2024 - Studies
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Events … Family Premiums for Employer-Sponsored Health Insurance
Growing Pain of Spinal Stenosis
Adverse … Drug Events Occurring in U.S.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
March 01, 2016 - The measure will provide a mechanism to help assess the
appropriateness of deliveries and prevent adverse … The evidence behind the inappropriate use of cesarean delivery and its link to increased risk of
adverse … We set the minimum number required as 10
events. … events. … evaluated at the minimum number of quality reporting events.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pdf
May 22, 2013 - • Nearly 20 percent of patients experience an adverse event
within a month of discharge, of which ¾ … could be prevented
• Common complications post-discharge are adverse drug
events, hospital-acquired
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www.talkingquality.ahrq.gov/research/findings/final-reports/index.html
June 01, 2023 - Studies
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Events … : Older Adults Publication Date: August 2022
Management of Direct Anticoagulants to Lower Adverse … Events in Atrial Fibrillation (MODL-AF) ( application/pdf 412143 ) Principal Investigators: King
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - for Ambulatory Surgery
6
Studies show that communication failures are the cause of 80 percent of adverse … for the entire team
Cards were placed in every operating room
Reduced wrong-site surgeries and other adverse … events
Increased staff morale
Reduced nursing turnover
4Shepard S. … Ensures all team members are on the same page
Confirms critical information
Provides a place to discuss adverse … or potentially adverse events that occurred
Facilitates discussion of how to stop problems from reoccurring
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www.talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module10/igmeasure.html
March 01, 2014 - Studies
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Events … PSIs are a set of measures that provide information about potential in- hospital complications and adverse … events (outcomes) following surgeries, procedures, and childbirth. … The PSIs can be used to help hospitals identify potential adverse events that might require further study … Such events can be mitigated with the implementation of TeamSTEPPS tools and strategies.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_1.pdf
October 01, 2016 - including lack of trust)
• What the patient brings (e.g., issues of trauma such as early childhood adverse … events)
Care is delivered primarily using an intensivist primary care team model, focusing on behavior … The LCSW may use
eye movement desensitization reprocessing and mindfulness to put childhood events into … Department
of Veterans Affairs] system, adverse childhood events can be a hidden driver of costs in … Early childhood experiences such as those uncovered using the Adverse
Childhood Experiences Survey may
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www.talkingquality.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - Studies
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Events … Clearly, the COVID-19 pandemic has further illuminated the scale and adverse impacts of this problem,
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www.talkingquality.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
February 01, 2018 - Studies
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Events … However, some medication-based treatments are likely to cause short-term adverse effects. … https://www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html