-
healthcare411.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
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/TS_OBC_Webinar_Plitt_FINAL.pptx
January 01, 2017 - patients with a diagnostic error
Paid medical liability claims (Bishop, et al., 2011):
Half related to events … When patients have difficulty with these self-management activities, they are at risk for adverse events
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pptx
November 19, 2008 - Proficiency
Slide
LEP
3
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
-
healthcare411.ahrq.gov/research/findings/final-reports/index.html?page=4
July 01, 2013 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Safety Publication Date: September 2012
Improving the Safety of Primary Care by Measuring Adverse … Events and Improvement ( application/pdf 516150 ) Principal Investigators: Kennerly, et al.
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
July 12, 2018 - diagnostic errors
were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse
-
healthcare411.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … Clearly, the COVID-19 pandemic has further illuminated the scale and adverse impacts of this problem,
-
healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
March 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Simulation is a technique that mimics real-world clinical events in a training environment so clinicians
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
December 01, 2020 - Importance of Patient Safety
Mortality
Prevalence
Cost
Findings on Patient Safety
Improving Trend: Adverse … Drug Events With Heparin and Factor Xa
Improving Trend: Inpatient Adverse Drug Events With Anticoagulants
-
healthcare411.ahrq.gov/news/newsletters/e-newsletter/816.html
May 01, 2022 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse
-
healthcare411.ahrq.gov/news/newsletters/e-newsletter/888.html
November 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Adverse drug event prevention and detection in older emergency department patients .
-
healthcare411.ahrq.gov/coronavirus/long-covid.html
March 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … pattern and progression or worsening over time, with the possibility of severe and life-threatening events … to improve the care of people living with multiple chronic conditions who are at increased risk for adverse
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
April 01, 2023 - Staff can use this decision tree when analyzing
an error or adverse event in an organization to help … events and close calls. … events, and near-misses. … These organizations consistently minimize adverse events despite carrying out
intrinsically complex and … drug events (ADEs).
-
healthcare411.ahrq.gov/teamstepps/instructor/essentials/implguide.html
November 01, 2018 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … supporting the need for a TeamSTEPPS Intervention could originate from a variety of sources, including adverse … Available organizational data, (e.g., adverse event and near miss reports, AHRQ Patient Safety Culture … so that facilities may also use the Guide to develop TeamSTEPPS Action Plans in response to sentinel events
-
healthcare411.ahrq.gov/funding/policies/nofoguidance/index.html
January 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Surveillance, measurement, detection, and reporting of patient safety events. … Determination of the clinical efficacy and effectiveness of preventive interventions, including unintended adverse
-
healthcare411.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
October 01, 2020 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
-
healthcare411.ahrq.gov/teamstepps/readiness/informationitems.html
April 01, 2016 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Objective information can originate from a variety of sources, including adverse event and near-miss
-
healthcare411.ahrq.gov/news/newsletters/e-newsletter/795.html
January 01, 2022 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … section
News
Newsroom
Blog
Newsletter
AHRQ News Now
Events … Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process
-
healthcare411.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
June 01, 2020 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_cord-prolapse.docx
May 01, 2017 - Defects (CUSP Module)
Key Perinatal Safety Elements
Examples
Debrief and analyze near misses and adverse … events related to cord prolapse … · A unit can decide its approach to debriefing events based on seriousness of event, expertise available … case reviews
Have a process in place to review severe maternal or neonatal morbidity and mortality events
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - These organizations consistently minimize adverse events despite carrying out
intrinsically complex and … events and close calls. … events, and near-misses. … • Eliminating Wrong Site Surgery and Procedure Events.
• MHS Leadership Engagement. … drug events (ADEs).