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Showing results for "adverse events".
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  1. cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-march2013.pptx
    January 01, 2013 - Understanding role of patients in patient safety, as well as barriers to engaging patients, can help reduce adverseevents and improve quality of care Scobie and Persaud.
  2. cahps.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
    December 01, 2017 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Percent know correct action for hypoglycemic symptoms 38 53.9 72.6 Slide 8 All Sentinel Events … limited health literacy: Poor compliance with medical management Increased risk of: Poor outcomes/adverseevents Infections/prolonged hospital stays Patient/family anxiety Slide 33 Summary: Health
  3. cahps.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
    March 01, 2017 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … In addition, the toolkit can enable teams to address root causes of adverse events more effectively. … It investigates events or safety concerns, and determines an appropriate course of action with the employees
  4. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
    July 01, 2018 - provide an overall grade on patient safety for their work area/unit and to indicate the number of events …  “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Hospital management seems interested in patient safety only after an adverse event happens ......... … Hospital management seems interested in patient safety only after an adverse event happens. … Frequency of Events Reported (Never, Rarely, Sometimes, Most of the time, Always) D1.
  5. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/icu.pdf
    March 19, 2014 - Discuss how an unmanaged workload may lead to adverse outcomes for a patient.
  6. cahps.ahrq.gov/ncepcr/tools/cultural-competence/planclas.html
    July 01, 2019 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Further, M+COs may not recognize the serious adverse health impact that lower levels of cultural competence
  7. cahps.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
    October 01, 2014 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Root cause analysis is a systematic process during which all factors contributing to an adverse event … Surveys are also labor intensive and rely on staff members' recall of specific events.
  8. cahps.ahrq.gov/sites/default/files/publications/files/postdisphone.pdf
    February 14, 2013 - Medicines High Alert Medicines Use the guide below to help monitor medicines with significant risk for adverseevents.
  9. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4v_combo_pdi10-sepsis-bestpractices.pdf
    May 17, 2016 - Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality
  10. cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/ready-change.html
    January 01, 2013 - Studies Blog AHRQ Views Newsletter AHRQ News Now Events … Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Have there been any adverse events that were fall related?
  11. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
    January 01, 2011 - • Sentinel events: transfusion reaction, wrong blood type, wrong-site surgery, foreign body left … in during procedure, medical equipment- related adverse events, medication errors … • Other care-related adverse events: patient falls, in-hospital hip fracture or fall http://www.oecd.org … Hospital of Philadelphia annually reviews all findings from root cause analyses of serious safety events … This electronic toolbox provides States with tools they can use or modify as they develop or improve adverse
  12. cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix3-data-abstraction.xlsx
    June 24, 2022 - utilization; NEST_data • The specific data elements required to assess performance and outcomes (including adverseevents and their timing) in the course of the disease or treatment; NEST_data • The appropriate settings … expectations or preferences will providers and patients be expected to have regarding benefits and adverse … NAM2019 Likelihood that beneficial or adverse effects would be reported or observed? … expectations or preferences will providers and patients be expected to have regarding benefits and adverse
  13. cahps.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - The remaining 2 studies (Giardina et al29,30) analyzed existing data sets of patient reports of adverseevents and patient complaints, respectively. … Secondary analysis of patient reports of adverse Timeliness, accuracy, communication events ( … The determination of error depends on the temporal or sequential context of events. … Tracking Progress in improving diagnosis: a framework for defining undesirable diagnostic events.
  14. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pptx
    July 01, 2012 - Proficiency Slide LEP 7 High-Risk Settings and Scenarios SAY: Research shows that patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study. … is inspired by the 2006 book by John Kotter, Our Iceberg Is Melting: Changing and Succeeding Under Adverse … Our iceberg is melting: changing and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events
  15. cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2018-materials/ts-obc-webinar-uw.pptx
    January 01, 2018 - patients experience a diagnostic error Paid medical liability claims (Bishop et al, 2013) Half arose from events … Paid malpractice claims for adverse events in inpatient and outpatient settings.
  16. cahps.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
    September 01, 2013 - Safety and Adverse Events 3 Introduction and Welcome This enhanced protocol is … from the manufacturer show that less than 1 percent of patients in clinical trials withdrew due to adverseevents. … /denominator of ICU patient days) by 1,000 = total events per 1,000 ICU patient days. … Product Safety and Adverse Events Chlorhexidine (CHG) Risk The risks associated with the use
  17. cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-091317.pptx
    January 01, 2017 - Leaders Team Perceptions Annual Culture of Safety HCAHPS - Satisfaction Core Measures Incident Reports AdverseEvents Switch Model Identify Coaches and Leaders Fundamentals of TeamSTEPPS Simulation Involve Pt.
  18. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
    August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverseevents and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … on the Centers for Medicare and Medicaid Services’ list of hospital-acquired complications “never events … communication during nurse transitions, for example: • Reduce the incidence of never events by 5 percent
  19. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pdf
    July 01, 2012 - LEP The Story of Willie Ramirez SAY: To illustrate why LEP patients are at risk of patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study. … is inspired by the 2006 book by John Kotter, Our Iceberg Is Melting: Changing and Succeeding Under Adverse … Our iceberg is melting: changing and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events
  20. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
    January 01, 2008 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverseevents. … •Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating … During a team huddle, response team members could: •Discuss critical issues and emerging events. … and prescribe a course of action for future events.

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