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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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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monahrq.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 adverse … events 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
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monahrq.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
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monahrq.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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monahrq.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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monahrq.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.
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monahrq.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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monahrq.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
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monahrq.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 adverse … events. … •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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monahrq.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
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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monahrq.ahrq.gov/hai/cusp/modules/spread/notes.html
December 01, 2012 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Ask:
How did the pilot CUSP team make a case for their project targeting adverse drug events?
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monahrq.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
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monahrq.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
April 01, 2017 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
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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monahrq.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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monahrq.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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monahrq.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.