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Showing results for "adverse events".
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381. Planning Culturally and Linguistically Appropriate Services | Agency for Healthcare Research and Quality
     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

382. Postdischarge Followup Phone Call Script (Patient Version) (pdf file)
     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.

383. Selected Best Practices and Suggestions for Improvement (pdf file)
     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

384. Specific Tools To Support Change (pdf file)
     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

385. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     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.

386. Appendix 3: Data Abstraction (xls file)
     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

387. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide
     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

388. OBC PPT Q4
     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.

389. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     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

390. Slide 1
     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.

391. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
     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

392. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide (pdf file)
     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

393. TeamSTEPPS: Rapid Response Systems (pdf file)
     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.

394. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     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

395. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality
     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?

396. Guide to Patient and Family Engagement in Hospital Quality and Safety | Agency for Healthcare Research and Quality
     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

397. TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) Manual | Agency for Healthcare Research and Quality
     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

398. Spreadnotes (doc file)
     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?

399. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     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

400. Readiness Assessment Survey (doc file)
     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.