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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
September 01, 2017 - Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … We understand that even small failures in safety protocols can lead to catastrophic or adverse events
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
January 01, 2011 - Washington state, improved the time from decision to the performance of a Caesarean section, with no adverse … Video Discussion
Think about the breakdowns you observed
in the stories:
Can you think of similar events … Of course, you would want to scrub them so that you're only sharing the sequence of events.
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pbrn.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
July 01, 2004 - collaborative patient-physician relationship (e.g.,
“Make sure your doctor knows about any allergies and adverse … Medications and adverse drug events are a key and often-cited patient safety
topic that patient behavior
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pbrn.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
July 01, 2021 - effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse … drug events, and preventable hospital readmissions ( Agency for Healthcare Research and Quality, 2018 … the provision of a treatment as appropriate), as well as both intermediate (e.g., disease control, adverse … patient safety events, patient experience) and definitive outcomes of care (e.g., quality of life, mortality
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lbpinject-topicref.pdf
March 03, 2014 - years of age and remains common in persons 65 years of age and older.3 Low back
pain can have major adverse … health care utilization
• For Key Question 4: Harms, including bleeding, infection, neurological events
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pbrn.ahrq.gov/hai/cusp/modules/nursing/nursing-notes.html
December 01, 2012 - Quality/Safety
Say:
Nurse managers should obtain data on quality outcomes and adverse events monthly
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pbrn.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
December 01, 2017 - So one event can lead to multiple other events, and I’m now on the slide – that is slide 6, I think – … Adverse drug events can lead to urinary retention, so the use of the catheter.
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pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
June 01, 2019 - Prevent adverse drug events.
Prevent central line infections.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
March 01, 2013 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/coursemgmt-cx062819.pdf
January 01, 2007 - materials is inspired by the John Kotter
(2006) book Our Iceberg is Melting, Changing and Succeeding Under Adverse … curriculum was
derived from John Kotter’s book Our Iceberg Is Melting: Changing and Succeeding Under
Adverse … teamstepps.ahrq.gov/abouttoolsmaterials.htm%23orderMaterials
☐ Ensure that all instructors know the sequence of events … • Incorporate only vignettes and examples from events that actually happened.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/coursemgmt.pdf
January 01, 2007 - materials is inspired by the John Kotter
(2006) book Our Iceberg is Melting, Changing and Succeeding Under Adverse … curriculum was
derived from John Kotter’s book Our Iceberg Is Melting: Changing and Succeeding Under
Adverse … teamstepps.ahrq.gov/abouttoolsmaterials.htm%23orderMaterials
☐ Ensure that all instructors know the sequence of events … • Incorporate only vignettes and examples from events that actually happened.
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pbrn.ahrq.gov/data/infographics/hac-rates-decline.html
August 01, 2018 - SHARE:
More topics in this section
Data & Analytics
Data Infographics
Data Visualizations
Data Tools
Data Innovations
All-Payer Claims Databases
Healthcare Cost and Utilization Project (HCUP)
Medical Expenditure Panel Survey…
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pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/healthited-issuebrief.pdf
February 01, 2021 - increased patient knowledge and was associated
with high trust in the physician, low CT use, and no adverse … patient events.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
March 28, 2006 - Kotter on change management, Leading Change and Our Iceberg is Melting: Changing and Succeeding Under Adverse … They've had some events that have occurred that really are rallying them now.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro-cx062819.pdf
January 01, 2007 - evidence-based care for acute myocardial
infarction, to prevent deaths from heart attack;
– Prevent adverse … drug events;
– Prevent central line infections;
– Prevent surgical site infections; and
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro.pdf
January 01, 2007 - evidence-based care for acute myocardial
infarction, to prevent deaths from heart attack;
– Prevent adverse … drug events;
– Prevent central line infections;
– Prevent surgical site infections; and
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pbrn.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
March 11, 2022 - Inadequacies of physical examination as a
cause of medical errors and adverse events: a collection of … Serious misdiagnosis-related harms in malpractice claims: The “Big Three” –
vascular events, infections … Internal medicine residents’
exposure to and confidence in managing hospital acute clinical events.
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pbrn.ahrq.gov/teamstepps/instructor/reference/learnbench.html
March 01, 2014 - Meeting as a team to debrief the events.
Explaining the protocol deviations.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
July 05, 2023 - Diagnostic Excellence, Mea-
sure Dx: A Resource To Identify, Analyze, and Learn From
Diagnostic Safety Events … If incentives are too
detailed, prescriptive, or misaligned, they may have adverse
effects on clinician
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/liquid-biopsy-topicrefinement.pdf
July 29, 2021 - KQ 2a KQ 2b
diagnosis
Intermediate
outcomes
False
positives and
negatives
Adverse … events
Figure 1 B. … validity
KQ 3a
KQ 3b
Intermediate
outcomes
False
positives and
negatives
Adverse … events
5
Background
Recent technologic advances have allowed for the isolation and … considered as a
relevant intermediate outcome
For diagnostic and treatment selection applications, “adverse