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preventiveservices.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
January 01, 2024 - Scope: The National Action Plan for Adverse Drug Event (ADE) Prevention identified three high-priority … Step 2 – Event Identification: An event summary was prepared
whenever the clinical pharmacist identified … The event summary also captured information to assess
the probability of an adverse event being attributable … investigators (AK, SS, SLK, JHG) for final event determination. … summary
information and classified the event as well as its severity and
preventability.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
May 01, 2017 - Specifications and
EMR Vendors
Functional specifications are available for On-Time reports for each adverse event … Investigate the root cause when an adverse event occurs. … The questions in each Self-Assessment Worksheet are tailored to the On-Time adverse event being addressed … discussion to help the Change Team decide how to use the On-Time reports to help prevent the adverse event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
April 01, 2018 - were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse drug event
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preventiveservices.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Afterwards, consider how the use of call-outs helped the team during an emergent event:
How did the … call-outs made by the nurse and intern aid the team during this emergent labor and delivery event?
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preventiveservices.ahrq.gov/hai/pfp/haccost2017.html
November 01, 2017 - Care-Associated Infections: Road Map to Elimination, 3 and the National Action Plan for Adverse Drug Event … Care-Associated Infections: Road Map to Elimination, 3 and the National Action Plan for Adverse Drug Event … feasible to incorporate clinical characteristics (e.g., laboratory test results) into patient safety event … replace the MPSMS and attempt to address some of the prior measurement limitations by 1) simplifying event … In the event that no substantial heterogeneity is observed from the random-effects model, we would then
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preventiveservices.ahrq.gov/npsd/data/dashboard/submissions.html
October 01, 2023 - percentage of reports by version, percentage of reports by report type, and percentage of events by event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
July 01, 2018 - No event reports d. 6 to 10 event reports
b. 1 to 2 event reports e. 11 to 20 event reports … c. 3 to 5 event reports f. 21 event reports or more
SECTION H: Background Information
This information … We are given feedback about changes put into place based on event reports.
C3. … Number of Events Reported
(No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports,
21 event reports or more)
G1.
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preventiveservices.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
December 01, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form.
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preventiveservices.ahrq.gov/news/blog/ahrqviews/academy-health-2022-meeting.html
May 01, 2022 - ARM is a premier event for health services research (HSR). … AHRQ is one of the participating Federal agencies supporting this important event, and it’s an honor
-
preventiveservices.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
May 01, 2023 - England Journal of Medicine that estimated 1 in 4 people hospitalized are at risk of a patient safety event … Trends in adverse event rates in hospitalized patients. JAMA 2022 Jul 12;328(2):173-83.
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preventiveservices.ahrq.gov/news/newsroom/case-studies/202201.html
January 01, 2022 - Pezzullo described their Safe Table event as a protected forum where participants can feel comfortable … After an IDD Safe Table event held in August 2020 for primary care physicians, attendee feedback forms
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - The use of these five sets of charts also eliminated the need to use 2005-2006
Medicare adverse event … Measures used to estimate the national HAC rate
HAC Type Source Measure
Adverse Drug
Event
MPSMS … Associated With Hip Joint Replacements
MPSMS Adverse Event Associated With Knee Joint Replacements … for all patients for
which the MPSMS data are used, we follow these steps:
• Multiply the adverse event … MPSMS Femoral Artery
Procedures
Puncture for Catheter Angiographic 21,538 0.72
MPSMS Adverse Event
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preventiveservices.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Condition Rate
Partnership for Patients Hospital-Acquired Conditions
Source
Measure
Adverse Drug Event … population, rather than as a rate for the subpopulation that has the opportunity to experience the adverse event … for each of the 21 HACs for all patients for which the MPSMS data are used, we multiply the adverse event … (rounded) (updated June 2014)
4,757,000
145
Ideally, we would have estimated the adverse event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2022.pdf
March 01, 2023 - • Common Formats for Event Reporting – Diagnostic Safety
o Released the Common Formats for Event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/data-collection-tool.xlsx
March 01, 2017 - CAUTI is an event which may continue for days or even weeks, but it is counted only once, not each day
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-II-508.pdf
January 01, 2021 - (Item A6*)
63% 68% 61% 61% 57% 59% 57%
When an event is reported in this unit, it feels like the … (Item C2) 73% 75% 77% 74%
In this unit, we are informed about changes that are made based on event … (Item A6*) 59% 63% 60% 62%
When an event is reported in this unit, it feels like the person is being … (Item A6*) 63% 63% 61% 63% 61% 57%
When an event is reported in this unit, it feels like the person … (Item A6*) 66% 51% 71% 64% 61% 79% 56% 55% 66% 62%
When an event is reported in this unit, it feels
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/success-stories/share_approach_success_story3_anthem.pdf
July 01, 2016 - They were pleasantly surprised to instead be part of an engaging event that offered
practical resources … Post-event survey results reflected participants’ informal comments to the training team.
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preventiveservices.ahrq.gov/evidencenow/heart-health/cholesterol/uspstf.html
September 01, 2018 - cardiovascular disease (CVD) and for those who have one or more CVD risk factors with a calculated 10-year CVD event
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - Staff can use this decision tree when analyzing an
error or adverse event in an organization to help … identify how human factors and systems issues
contributed to the event. … Staff can use this decision tree when
analyzing an error or adverse event in an organization to help … identify how human factors and
systems issues contributed to the event. … Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management
5.
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preventiveservices.ahrq.gov/news/events/index.html
November 01, 2022 - Skip to main content
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