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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
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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.
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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 .)
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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.
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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
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/icu.html
March 01, 2014 - Discuss how an unmanaged workload may lead to adverse outcomes for a patient.
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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.
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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
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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
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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?
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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?
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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
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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
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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.
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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
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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
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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
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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
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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.
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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.