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healthcare411.ahrq.gov/data/infographics/hac-rates-decline.html
August 01, 2018 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events
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healthcare411.ahrq.gov/ncepcr/tools/cultural-competence/oralling.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 inadequate linguistic services
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/workforce-executive-summary.pdf
October 01, 2016 - traditional “promotora,” or health promoter, roles
in the community, conducting outreach at community events … Cutting-edge innovation: Practices use screening tools such as the Adverse Childhood Events
Survey to
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem. … Memo on never events, July 7, 2008.
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healthcare411.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
October 01, 2020 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Slide Time: 5 minutes
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.
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healthcare411.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 adverse … events and improve quality of care
Scobie and Persaud.
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healthcare411.ahrq.gov/news/newsroom/ahrq-stats.html
November 01, 2023 - (Source: Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem Inflammatory … Measures showing the most improvement included reduced adverse events among hospital patients receiving … (Source: Healthcare Cost and Utilization Project Statistical Brief #237: Patient Safety and Adverse … Events, 2011 and 2014 .) … Events, 2011 and 2014 .)
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healthcare411.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.
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healthcare411.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.
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healthcare411.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
March 01, 2017 - Studies
Blog
AHRQ Views
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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
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healthcare411.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/adverse … events
Infections/prolonged hospital stays
Patient/family anxiety
Slide 33
Summary: Health
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healthcare411.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.
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healthcare411.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 adverse … events.
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healthcare411.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
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healthcare411.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
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
August 01, 2010 - Nurse shift changes require the successful transfer of information between nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … are 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
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healthcare411.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
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healthcare411.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
adverse … events 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.
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healthcare411.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.
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healthcare411.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
Adverse … Events
Switch Model
Identify Coaches and Leaders
Fundamentals of TeamSTEPPS
Simulation
Involve Pt.