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monahrq.ahrq.gov/news/newsletters/e-newsletter/824.html
August 01, 2022 - Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic
Medication-related … "Medication is just one piece of the whole puzzle": how nursing homes change their use of antipsychotic
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxreports.pptx
October 01, 2017 - mental status change
New unsafe behaviors
New gait/balance problem or mobility device
New fall
New medication … Condition data:
Acute Mental Status Change
Behavior: New Unsafe
New Gait/Balance or Device Order
New Fall
Medication … : New Medication or Dose Change
Orthostatic Hypotension/Dehydration
Vertigo/Dizziness
Syncope/Fainting … HREC 1: Mental Instability
HREC 2: Gait and Balance Instability
HREC 3: Fall History
HREC 4: High-Risk Medication … improper use X X
Equipment failure, bed, chair, floor mat alarms
Potential medication
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monahrq.ahrq.gov/news/newsletters/e-newsletter/901.html
February 01, 2024 - Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory … An mHealth design to promote medication safety in children with medical complexity.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-slides-final508.pptx
April 04, 2018 - A new diagnosis
Medication need and proper use
Home care instructions
Recommended behavior changes
Treatment … Medication need and proper use.
Home care instructions.
Recommended behavior changes. … chronic condition, such as asthma or diabetes
First and last patient of the day
Patients with a new medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-slides-final508.pdf
April 11, 2018 - • A new diagnosis
• Medication need and proper use
• Home care instructions
• Recommended behavior … Medication need and proper use.
Home care instructions.
Recommended behavior changes. … chronic condition, such as asthma or diabetes
First and last patient of the day
Patients with a new medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with medication … questions:
Causes for concern:
Diagnosis
Documentation/communication
Infection
Medication … Thrombolytic Therapy
• STK-5 Antithrombotic Therapy By End of Hospital Day 2
• STK-6 Discharged on Statin Medication
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monahrq.ahrq.gov/news/newsletters/e-newsletter/872.html
July 01, 2023 - Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication … managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy/sahl-e-form-user-guide.pdf
December 18, 2014 - Distracter
1. kidney __urine __fever __don’t know
2. occupation __work __education __don’t know
3. medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/diagnostic-safety-workgroup-march-2022-meeting-notes.pdf
January 01, 2022 - a pharmacist-led hospital-community
collaborative transitions of care (TOC) program to decrease
medication-related
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monahrq.ahrq.gov/news/newsletters/e-newsletter/846.html
January 01, 2023 - A failure in the medication delivery system—how disclosure and systems investigation improve patient … Association between hospital-physician vertical integration and medication adherence rates.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
July 12, 2018 - visits
1 in 9
ED admissions
are related to an
adverse drug event
An estimated
160
million
medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/leputcomesasst.pdf
July 25, 2012 - Chin: “Take this
medication once every 12 hours, with food.” The patient looks confused.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepslstafftrain.pptx
February 02, 2006 - High-Risk Settings and Situations
ED
OB/GYN
Surgery
Transitions in care, including intake and discharge
Medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-checklist-nomeds-final508.pdf
April 03, 2018 - List
When patient does NOT bring medicines
Starting the Process
� Use the word “medicine” instead of medication
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monahrq.ahrq.gov/data/infographics/health-care-quality.html
September 01, 2018 - 18
Top Performing States: Highest Percentage of Stroke Patients Who Received Blood Clot Prevention Medication
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monahrq.ahrq.gov/patient-safety/reports/healthaffairs.html
March 01, 2019 - its commitment to lead patient-safety efforts nationwide, AHRQ has funded studies that aim to reduce medication
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monahrq.ahrq.gov/hai/hac/tools.html
March 01, 2024 - Hospitals
Adverse drug events: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication
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monahrq.ahrq.gov/sites/default/files/wysiwyg/news/events/conference/2011/jack/jack.pptx
January 01, 2011 - Qualitative
Analysis
Root Cause
Analysis
7
7
RED Checklist
Eleven mutually reinforcing components:
Medication … , few minutes with nurse/doctor
Personalized cover page
Updated list of all medicines
MEDICATION
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monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
January 01, 2017 - Prescribed
some pain medication. … We discussed pros and
cons and decided to continue the medication
I got a bill from my doctors office
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-bestpractices.pdf
May 20, 2016 - between the provider, pharmacist, nurse, and patient (including the
family if applicable) regarding medication … reconciliation and the outpatient medication
regimen