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Showing results for "adverse events".
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  1. pbrn.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
    October 01, 2020 - 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. … identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events
  2. pbrn.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.
  3. pbrn.ahrq.gov/news/newsroom/ahrq-stats.html
    November 01, 2023 - AHRQ Social Media AHRQ Stats Impact Case Studies Blog Newsletter Events … (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 … Events, 2011 and 2014 .) … Events, 2011 and 2014 .)
  4. pbrn.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.
  5. pbrn.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
    March 01, 2017 - 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
  6. pbrn.ahrq.gov/teamstepps/instructor/scenarios/icu.html
    March 01, 2014 - Discuss how an unmanaged workload may lead to adverse outcomes for a patient.
  7. pbrn.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 adverseevents.
  8. pbrn.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
  9. pbrn.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-slides.html
    December 01, 2017 - 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/adverseevents Infections/prolonged hospital stays Patient/family anxiety Slide 33 Summary: Health
  10. pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/ready-change.html
    January 01, 2013 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Have there been any adverse events that were fall related?
  11. pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
    October 01, 2014 - Patients and Families About AHRQ's Quality & Patient Safety Work Patient Safety News and Events … Have there been any notable adverse events that were pressure-ulcer related?
  12. pbrn.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 adverseevents 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
  13. pbrn.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
  14. pbrn.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 adverseevents 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.
  15. pbrn.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 adverseevents 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
  16. Scisafetynotes (doc file)

    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
    September 04, 2012 - . · On average, every patient admitted to an intensive care unit suffers an adverse event. · 44,000 to
  17. pbrn.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 adverseevents. … /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
  18. pbrn.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 adverseevents 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
  19. pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
    January 01, 2008 - should be prioritized based on the risk to patients and on the prevalence and severity of targeted adverseevents. … Quality Improvement – Supports Activators and Responders by reviewing RRS events and evaluating data … During a team huddle, response team members could: Discuss critical issues and emerging events. … and prescribe a course of action for future events.
  20. pbrn.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 adverseevents. … •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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