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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the … Hospital management seems interested in patient safety only after an
adverse event happens ....... … 1 2 3 4 5
SECTION G: Number of Events Reported
In the past 12 months, how many event reports
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - ------------------------------------------------------------------- 9
How to prevent adverse events … one study.1 Of these adverse events, three-quarters could
have been prevented or ameliorated. … At this time, no
consensus exists on the single best method to prevent adverse events after
discharge … The incidence and severity of adverse
events affecting patients after discharge from the hospital. … How to prevent adverse events after discharge
How does the IDEAL Discharge Planning strategy improve
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pbrn.ahrq.gov/patient-safety/settings/multiple/index.html
August 01, 2023 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … PSOs can help providers develop successful approaches to improving quality and reducing adverse outcomes … Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events is a resource to … help healthcare organizations detect, analyze, and learn from diagnostic safety events. … organization interested in promoting diagnostic excellence and reducing harm from diagnostic safety events
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pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring, mutual support … Staff members are concerned that we could have an adverse event due to breakdowns in team skills.
… prophylactic use of beta-blockers to prevent intra-operative myocardial ischemia]; decreased rates of adverse … events or near misses)
Who will be involved in the change?
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
April 01, 2011 - 9
How to prevent adverse events after discharge 11
How does the IDEAL Discharge Planning strategy improve … study.1 Of these adverse events, three-quarters could have been prevented or ameliorated. … How to prevent adverse events after discharge
Many of the challenges described above can be attributed … At this time, no consensus exists on the single best method to prevent adverse events after discharge … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-roster-2023dec.pdf
December 21, 2023 - Medical Officer
Name Department/Agency Title
Michael Lee, Pharm.D.,
BCPS, CAPT, USPHS
IHS IHS Adverse … Events Coordinator, IHS Office of
Quality, Division of Quality Assurance and
Patient Safety
Phillippe
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pbrn.ahrq.gov/research/publications/search.html
January 01, 2024 - considers how to most effectively elicit representative, in-depth narrative accounts of diagnosis-related events … enrich clinicians’ understanding of patient and family experience and reduce the harms that follow adverse … diagnostic events.
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pbrn.ahrq.gov/teamstepps/webinars/previous-webinars-2013.html
August 01, 2017 - Identify common causes of adverse events for LEP and culturally diverse patients. … strategies for improving detection of medical errors and preventing high-risk scenarios from becoming safety events … Provide an approach to preventing safety events through the use of TeamSTEPPS tools.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - multidisciplinary review is required to identify system processes that may result
in failures in care, adverse … events, and mortality … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … department within 3 days of discharge
∗ Death associated with drug reaction
∗ Death associated with adverse … Summary data of sentinel events reviewed by The Joint Commission.
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pbrn.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
September 01, 2016 - More topics in this section
News
Newsroom
Blog
Newsletter
Events … for health care safety and quality in a variety of fields, including patient engagement, response to adverse … events, diagnostic error reduction, rapid response, and infection prevention, among others. … events within the Medicare population. … paper, and led the AHRQ-Brigham medication safety HIT CERT CEDAR (Calling for Earlier Detection of Adverse
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pbrn.ahrq.gov/cpi/about/otherwebsites/PBRN/pbrn.html
September 01, 2018 - Field testing of a new ambulatory care electronic Medication Errors and Adverse Drug Events Reporting
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - ”
· “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … questions when something does not seem right
1
2
3
4
5
9
SECTION D: Reporting Patient Safety Events … In the past 12 months, how many patient safety events have you reported?
a. … Hospital management seems interested in patient safety only after an adverse event happens
1
2
3
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pbrn.ahrq.gov/news/newsroom/case-studies/202301.html
March 01, 2023 - AHRQ Social Media
AHRQ Stats
Impact Case Studies
Blog
Newsletter
Events … AHRQ Product(s):
SHARE Approach
Topic(s):
Access to Care,
Adverse … Drug Events (ADE),
Care Coordination,
Chronic Conditions,
Clinician-Patient Communication
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
May 01, 2017 - Admin.
10
Key Safety Elements: Learn From Defects
Debrief and analyze near misses and adverse events … inductions outside of policy-defined indications
severe maternal or neonatal morbidity and mortality events … Admin.
23
Key Safety Elements: Learn From Defects
Debrief near misses and adverse events related … magnesium sulfate outside of defined indications
severe maternal or neonatal morbidity and mortality events … Consider these factors:
Unit data suggesting adverse events or near misses related to oxytocin, magnesium
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
November 03, 2022 - of our resource – Measure Dx: A
Resource To Identify, Analyze, and Learn From Diagnostic Safety
Events … IHS • Enhanced Adverse Event Reporting Capabilities
o IHS Safety Tracking and Response (I-STAR) is deployed … Current projects include working on overdue events
and development of standardized reporting at the
-
pbrn.ahrq.gov/talkingquality/explain/share-info/highlight.html
September 01, 2019 - For example, in the next few years, we may see systems that enable patients to report on adverse events
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol.pdf
February 02, 2018 - These physiologic aberrations may result in
several adverse outcomes that include, but are not limited … events? … events
• Timing
o At least 1 month of treatment
• Setting
o Home
o Assisted living residence … (KQ 5)
Adverse
Events
Table 1. … events
Timing At least 1 month of treatment in
home settings
None
Settings Therapy (BPAP, CPAP
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
January 01, 2021 - ”
• “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … 1 2 3 4 5 9
5
SECTION D: Reporting Patient Safety Events
Think about your unit/work … In the past 12 months, how many patient safety events have you reported?
a. … Hospital management seems interested in
patient safety only after an adverse event
happens .......
-
pbrn.ahrq.gov/news/blog/ahrqviews/deep-dive-into-covid19.html
June 01, 2023 - this section
News
Newsroom
Blog
AHRQ Views
Newsletter
Events … healthcare is understanding and quantifying the impacts of the COVID-19 pandemic and how we can mitigate the adverse … effects of these kinds of catastrophic events in the future.
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pbrn.ahrq.gov/teamstepps-program/resources/additional/index.html
September 01, 2023 - techniques used in labor and delivery units can help improve communication and collaboration and reduce adverse … this technique, one tool in the TeamSTEPPS 3.0 training program, can improve communication, reduce adverse … events, and improve care quality.