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healthcare411.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 adverse … events. … /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
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healthcare411.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 adverse … events 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
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healthcare411.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - Studies
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Events … Hospital-Acquired Conditions show that national efforts to reduce hospital-acquired conditions, such as adverse … drug events and injuries from falls, helped prevent an estimated 8,000 deaths and save $2.9 billion
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healthcare411.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Studies
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Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
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healthcare411.ahrq.gov/hai/cusp/modules/spread/notes.html
December 01, 2012 - Studies
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Events … Ask:
How did the pilot CUSP team make a case for their project targeting adverse drug events?
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healthcare411.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
April 01, 2017 - Studies
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Events … safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … The 50-item T-TPQ was tested and refined during three critical events: cognitive interviews, small group
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - ASK:
· How did the pilot CUSP team make a case for their project targeting adverse drug events?
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - physician to observe overt and
many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting
a case and receiving feedback.42 The study reported a significant reduction in adverse … events and near-
misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency
department
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
July 12, 2017 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.docx
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive professional interpretation services.3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.docx
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive professional interpretation services.3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot study.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/readiness/tsreadiness.pdf
August 01, 2005 - Objective information
can originate from a variety of sources, including adverse event and near-miss
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
August 01, 2005 - Objective information
can originate from a variety of sources, including adverse event and near-miss
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
September 02, 2022 - Discuss the associated tasks and thought
processes taking place during those events.
4
Domain 3: … SBAR),27-30 to structure communication with physicians and other diagnostic team
members and reduce adverse … events. … in their day-to-day operations.
7
e
Any safety events or “good catches” identified from these … Measure Dx: A Resource To Identify, Analyze, and Learn
From Diagnostic Safety Events. July 2022.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.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.
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healthcare411.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
September 01, 2017 - Studies
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Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … We understand that even small failures in safety protocols can lead to catastrophic or adverse events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.docx
April 30, 2013 - opportunities where they can interact with the health care team
This handout gives information on routine events … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … Communicating to Improve Quality strategy may also help to meet other goals related to patient safety and never events
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.pdf
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more
severe and … professional interpretation services.
3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot
study.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.pdf
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more
severe … professional interpretation services.
3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot
study.
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healthcare411.ahrq.gov/funding/process/study-section/prrvmtgs.html
March 01, 2024 - Studies
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