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Showing results for "adverse events".
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321. Train-the-Trainer Instructor Guide | Agency for Healthcare Research and Quality
     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

322. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
     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.

323. AHRQ Stats | Agency for Healthcare Research and Quality
     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 .)

324. TeamSTEPPS Specialty Scenarios: ICU (pdf file)
     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.

325. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     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

326. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/scenarios/icu.html
     March 01, 2014 - Discuss how an unmanaged workload may lead to adverse outcomes for a patient.

327. Postdischarge Followup Phone Call Script (Patient Version) (pdf file)
     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 adverse … events.

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

329. Health Literacy and Patient and Family Engagement: Strategic Tools to Prevent CAUTI | Agency for Healthcare Research and Quality
     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/adverse … events Infections/prolonged hospital stays Patient/family anxiety Slide 33 Summary: Health

330. 1. Are you ready for this change? | Agency for Healthcare Research and Quality
     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?

331. 1. Are we ready for this change? | Agency for Healthcare Research and Quality
     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?

332. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
     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 adverse … events 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

333. Specific Tools To Support Change (pdf file)
     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

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

335. Appendix 3: Data Abstraction (xls file)
     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 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

336. 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

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

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

339. SITUATION MONITORING (ppt file)
     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 adverse … events. … 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.

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